PUERPERIUM

The problems of breastfeeding in most cases can be from lack of experience and inadequate knowledge on the intricacies of breastfeeding. Also, it can be from cultural beliefs, health and socio-economic influences. As a follow up article on the problems of breastfeeding part one, outlined below are additional problems and challenges of breastfeeding that are quite common. The World breastfeeding week ends today. Mothers should be supported to encourage exclusive breastfeeding.

THE PROBLEMS OF BREASTFEEDING: NIPPLE CONFUSION

Babies are born with the natural instinct for breastfeeding. If you poke a baby’s cheek with your finger, the natural response is for the baby to turn to that side with the mouth open. This is called the rooting reflex. Nipple confusion arise from the baby’s difficulty to switch from bottle feeding to breastfeeding. In new born babies introduced to pacifier or bottle feeding, they may have difficulty latching onto the breast.  For older babies, they may start preferring the bottle feeding to breastfeeding.

In fact, breastfeeding is difficult for the baby than bottle feeding. So, it is normal for the baby to prefer the easy one. You will often hear parents say the baby stopped breastfeeding on its own. This is so because the baby was most likely introduced to a pacifier or bottle feeding. Note that not all babies will develop nipple confusion. One cannot tell which baby will have nipple confusion, therefore, prevention is key by avoidance of the stimulus.

INVERTED OR FLAT NIPPLES

The nipple is a small conical structure on the breast. A normal nipple should point outward and not appear flatten. A flattened or inwardly drawn nipple poses a great deal of challenge as one of the problems of breastfeeding. This makes latch on difficult. It is important for an inverted nipple to be discover early. This could be during breast self examination or usually at the antenatal care booking clinic during the clinical breasts examination.

Hence, necessitating breast preparation before delivery. So, attempts are made to pull the nipples out. Using the Hoffman exercise, the thumbs are placed on either side of the flat or inverted nipple on the left and right side of the areola. A slight inward then firm outwards pressure is applied on the areola. This manoeuvre should be repeated circumferentially at least 5times a day.

Also, a suction cup device, hard plastic breast shells or syringe can be used to attempt pulling out the flat or inverted nipple. Using a syringe, the other end away from the plunger is cut circumferentially, the cut end is applied to the breast around the nipple. The plunger is withdrawn and the suction pressure pulls the nipple out. Several attempts will be needed to make the nipple point out. This can be done before each feeding episode. The breast shells are worn inside the bra, they put pressure around the nipple making it protrude.

Whereas, the aforementioned methods may give results though not permanent, some expert have questioned their efficacy. Surgery has been advocated and one of such procedure is the nipple piercing. The flat or inverted nipple is elevated and pierced leaving a small horizontal bar to keep it elevated.

MASTITIS

Mastitis is the inflammation of the breast tissue resulting from infection or breast engorgement. Both or one breast might be affected. Affected individual could have breast pain, mild fever, malaise, nausea or vomiting. Treatment depends on whether the woman is breastfeeding or not. If she is breastfeeding, she should continue even on the affected breast. Manual expression of milk after breastfeeding will also help if the mastitis is due to engorgement.

If she is not breastfeeding, a tight fitting bra can be use, usually, the bra size she uses when she was not pregnant is advised. Medication can also be used to suppress breast milk production. For infectious mastitis, antibiotic is recommended.

BREAST ABSCESS

A breast abscess is formed when pus collect in the breast. Mastitis or secondary infection of a galactocele can result in breast abscess. Affected women come down with breast pain, fever, nausea or vomiting. The nipple may discharge pus; the surface of the breast may be warm, appear red-like, swollen; and there may be a punctum. Treatment here is by incision and drainage of the pus. Breastfeeding should be withheld on the affected breast.

UNSUPPORTIVE WORK PLACE POLICIES

Unsupportive work place policies are a major contributor to the uptake of exclusive breastfeeding. Women are a significant part of the work force in most countries. Married women will want to have babies since nature did not confer them with the advantage that they can afford to wait too long. So, in the course of their career progression, a child might come into the picture. They need all the support within and without to get through this period of raising a healthy child. An exclusively breastfed child will fall ill less often thereby, reducing the burden on the health system. Also, mothers will take less time away from work to take their babies to the hospital.

However, the work place might not be conducive enough to support exclusive breastfeeding. Maternity leaves should be at least six months to allow for exclusive breastfeeding and it should be a paid leave. Some organization do not have crèche where these babies can stay while their mothers work and intermittently come to breastfeed. Those that have crèches have no breastfeeding breaks.

Also, some mothers do not get the require duration of maternity leave as stipulated by law. Reason being that they have not spent up to six months at the said employment before delivery. Despite the reduction in the official leave period, some do not get paid during the period while they are on leave. For this reason, the law makers should take responsibility for making laws that will encourage exclusive breastfeeding. Also, enforce and ensure compliance with the law both in the public and private sectors. The Ministry Of Women Affairs should be in the vanguard of ensuring compliance with the laws. Also, ensuring women on maternity leaves are paid.

The problems of breastfeeding can be quite overwhelming especially for the new mothers. As easy as breastfeeding might look, it can be very challenging. Breastfeeding is cost-effective but not cheap if you consider the sacrifice needed to succeed. A lot of time, patience, loss of sleep, understanding and above all support will be needed for a successful breastfeeding experience.

When care is not taken, the problems and challenges of breastfeeding might result in a poor breastfeeding experience for the mother and child. Knowing the benefits of breastfeeding might just be the only encouragement to continue. Some of the problems and challenges of breastfeeding are outlined below.

THE PROBLEMS OF BREASTFEEDING: INADEQUATE BREAST MILK PRODUCTION

In a woman with normal breasts, the breast milk is very adequate for the baby by nature’s design. The production is dynamic to meet the need of babies at each point in time in their growth and development. The production of breast milk is in two phases. The first phase starts from about 12 weeks during pregnancy. The second phase starts about 2 to 4 days after birth. The suckling effect of the baby is the key to unlocking the second phase.

Importantly, early commencement of breastfeeding is very crucial to achieving early and adequate milk production. It is recommended that babies should be put to breast immediately after delivery, at most, 30 minutes to one hour after delivery. Late initiation of breastfeeding or giving the baby other food will interfere with initiation of breastfeeding and adequacy of milk production.

BREAST MILK IS NOT ALWAYS ENOUGH FOR BABIES.

Some people belief that the breast milk is not always enough for babies especially male babies. This is not true for a normal breast. After birth, the production is usually small for some women but it will later pick up. The gradual increase in production should not be a cause of concern, even if it is as small as 2 to 5mls that is produce at the initial feeding. With frequent stimulation by the baby through suckling, the production will improve. You should also note that the new born stomach capacity is very small, about 5 to 7ml on the first day of life to about 20ml on the 3^rd day of life.

Moreover, women with adequate breast milk production still complain of their babies crying after a short while following feeding. This is not due to the milk not been enough, the problem here is quality of feeding time. The mature breast milk is composed of the fore milk and the hind milk. The fore milk is mostly fluid while the hind milk contains fat. It is this part of the mature milk that gives satiety and fills the baby. To get to the hind milk, the baby should suckle for at least 20 minutes on one breast without switching to the other breast.

SORE OR CRACKED NIPPLE

The nipple can feel sore during or after breastfeeding, this should normally not happen. One of the common cause is mostly due to poor latch on. This result in the baby suckling on the nipple. After breastfeeding, take a look at the nipple, if it is flat or wedge shaped, the baby was not properly latched on the breast. If this continue, it can result in injury to the nipple called cracked nipple.

If the nipple is cracked, you should visit your healthcare provider for instruction on proper positioning and signs of proper latch on. Continue breastfeeding as before even on the affected breast to avoid engorgement. With proper latch on, you will not feel pain while breastfeeding on the breast with a cracked nipple. At the end of feeding, smear the nipple with breast milk. The breast milk contains enzymes and growth factors that will help with the healing process.

If you still feel pain with proper latch on, it might be from infection with candida. Look out for oral thrush in the mouth of your baby. These are whitish patches on the tongue, gum, cheek or roof of the mouth that won’t come off easily with gentle cleaning with a cotton bud. For this, both mother and baby will need antifungal medication for treatment. 

BREASTS ENGORGEMENT

The breasts can become swollen and painful if left to accumulate due to missed feeding periods. This is common in women who work in establishment that do not support breastfeeding mothers. It is important to have crèche within the mother’s work environment where she can sustain continuous breastfeeding.

Consequently, the brain sends chemical signal to stop further production when the one already produced is not been used. Therefore, continuous breast engorgement will affect milk production. The solution to this is to express the milk and store in a refrigerator while at work. This will not only relief the pressure but sustain production.

contrary to certain belief, the breast milk while still in the breasts cannot get sour. Even if you have not breastfed your baby for more than 24hrs, do not express and discard before feeding.

GALACTOCELE

The nipple is pierced by about 12 to 20 ducts that drain milk from the lactiferous sinuses. Please read here for a brief anatomy of the breast. When a breast duct is blocked, milk accumulate in the breast lobe drain by the duct to form a milk cyst called galactocele.

In this case, the blockage can result from trauma, inflammation or abnormalities of the nipple. Mothers who breastfed intermittently or use formula feed are more likely to develop a milk cyst. This is due to incomplete evacuation of the milk from the lactiferous sinus.

Usually, a galactocele is not painful and there is no fever. It is a firm, non-tender, single mass felt in the breast. Any mass in the breast has to be investigated to make sure it is not cancer. An ultrasound scan is useful. Treatment will be by aspiration of the cyst. Blocked duct can result in mastitis.

To be continued, the problems of breastfeeding part two.

Mothers and aspiring mothers need to know the enormous benefits of breastfeeding. It might just be the encouragement they need to go through the period successfully. There is no better time to support and promote breastfeeding than now; the World Breastfeeding week which kicked off from 1^st to 7^th August, 2022. The theme for this year’s commemoration is, ‘Step up for Breastfeeding: Educate and Support’. Breast milk is nature’s wonder that contains all the nutrient your baby need at each stage of life.

THE BENEFITS OF BREASTFEEDING

According to the World Health Organization, about 2 out of 3 children are not exclusively breastfed for the recommended 6months. Despite the many benefits of breastfeeding, the uptake of exclusive breastfeeding has not improved. According to the Nigerian Demographic and Health Survey data of 2018, only 29% of babies were exclusively breastfed, 22% of babies under 6months had breast milk with complimentary foods, 48% had breast milk with other liquids while 2% were not breastfed.

According to the United States of America Centre for Disease Control in 2019, about 24.9% of babies under 6months had exclusive breastfeeding while 35.3% had supplemental infant formula with breastfeeding. These statistics are not encouraging.

The benefits of breastfeeding to the baby include:

• Immunity to the baby; it provides protection to the baby from infectious agents the mother was exposed to.
• Plays a role in the development of a healthy intestinal flora that helps to reduce allergy, inflammatory bowel disease and diarrhoea disease
• Early breastfeeding promote tolerance and reduces the incidence of food allergies
• The docosahexaenoic acid (DHA) is an omega-3 fatty acid found in breast milk that is belief to help in visual and brain development of both the unborn and breastfed babies.
• Exclusively breastfed babies tend to have higher intelligence quotient (IQ)
• Breastfeeding can be used to comfort the baby; the fastest way to stop a baby from crying is breastfeeding.

The benefits of breastfeeding to the mother include:

• Reduces the risk of breast cancer
• Reduces the risk of ovarian cancer
• Prevent bleeding after delivery
• Help in losing the additional weight gained during the pregnancy period.
• Encourage mother and child bonding

To the environment, breastfeeding is eco-friendly as it does not generate waste for disposal.

BREASTFEEDING INITIATION         

It is recommended that breastfeeding should be initiated immediately after delivery, as soon as the mother is stable. It is recommended to start within 30 minutes to 1hours of delivery even if the delivery was by caesarean section. Breastfeeding should be on demand or every 2 to 3hour. You may have to wake your baby up to breastfeed, if the baby sleeps for more than 3hrs. Breastfeeding should be exclusive; giving only breast milk for 6months either directly from the breast or expressed breast milk. Complimentary feeds should be introduced at 6months. Breastfeeding should continue for one year and beyond.

For women with hepatitis B virus infection, breastfeeding should start immediately after the baby receives hepatitis B virus immunoglobulin and vaccine. For HIV positive patient that opted for breastfeeding, the baby should be given antiretroviral medication for pre-exposure prophylaxis before initiating breastfeeding. HIV expose babies on prophylaxis should be breastfed exclusively till 6months. Complimentary feed should be introduced thereafter with breastfeeding continuing till one year.

COMPOSITION OF BREAST MILK

The composition of the breast milk changes with time and feeding. The first milk is called the colostrum which is produced within the first 4days after delivery. Its colour varies depending on maternal dietary level of β-carotene. It might be yellow, orange or light brown. After 4days, the transitional milk takes over. The mature milk starts 14days after delivery. The mature milk is composed of the foremilk and the hind milk.

The foremilk is predominantly fluid and the hind milk is high in fat. The baby needs to suck for at least 30minutes to get the both components of the mature milk. The hind milk is responsible for satiation. Babies will cry often if they do not stay long on the breast to get the hind milk. Ensure the baby empties one breast before changing to the next.

Also, the breast milk is composed of macro-nutrients, micro-nutrients, growth factors and enzymes. One of my trainers describe the breast milk as, ‘’milk a life’’ due to the presence of the enzymes. The enzyme lipase helps the child to handle the digestion of fat. The macro-nutrients include; carbohydrate with oligosaccharide inclusive, oligosaccharide promote the growth of favourable bacteria that protects the baby’s intestine; protein and fat.

The micro-nutrients consist of vitamins, calcium, iron and zinc. The growth factors such as epidermal growth factor, platelet derived growth factor, vascular endothelial growth factor and insulin-like growth factor.

Furthermore, breast milk is specific to the mother. It contains immunoglobulin A, E G and M. The immunoglobulins contained in breast milk depend on the maternal exposure to infectious agents. These are passed to the baby to provide passive immunity to prevent infection and allergy.

TECHNIQUES OR POSITIONING FOR BREASTFEEDING

There are several techniques of breastfeeding, the common one is the sit up position.

• The mother sit upright with her back well supported
• The back of the baby’s head in front of her elbow
• Her open palm supports the buttock of the baby
• The mother brings the baby to the breast and not bend towards the baby. Note that bad posturing will cause back ache and affect the breast feeding experience.
• A pillow can also be placed on the mother’s thigh for support too.
• With the other hand, the mother can support the breast with her four fingers beneath and the thumb above the breast. Note that this is just to support the breast and not for pressing or milking the breast. Pressing the breast will obstruct the milk duct.

WHAT CONSTITUTE A PROPER LATCH ON?

Proper latch on or attachment to the breast during breastfeeding ensures that the baby is getting the breast milk. If the baby is not properly latched, the child will be suckling on the nipple and this can result in cracked nipple. Proper latch on consist of the following;

• The baby’s lips should be wide open and everted
• The baby’s lips should cover most of the areola which is the pigmented part of the breast after the nipple
• There should be no suckling sound. If you hear this, the baby is not properly latch
• You should hear swallowing sound
• You can also see milk at the angle of the baby’s mouth.

PROBLEMS OF EXCLUSIVE BREASTFEEDING

The problems of breastfeeding are outlined below;

• Not enough milk production
• The belief that breast milk is not enough for babies
• Sore or cracked nipple
• Breasts engorgement
• Mastitis
• Breast abscess
• unsupportive work policies

Did you just deliver a baby and you are feeling sore or discomfort around your vagina? Did you sustain some laceration during delivery? This is for you if your answer is yes. The perineum is the area around the vagina excluding the anus. Care of both the perineal and anal region is very important for all women and not only those who just had a baby. Using a tissue paper is ok but washing with water is great after urinating, sexual intercourse and defecating. The care of these regions is very important after delivery especially if you had a couple of stitches to repair the injury caused by the baby as it passes through the vagina. This will help prevent infection and opening of the stitched wound.

Sitz bath is a bath in which the buttocks are dipped up to the level of the hips in water. It is can be done using warm, cool or alternating between a warm and cool water. Salt, vinegar or baking soda can be added to the water or the water can be used alone. For the purpose of caring for the injury in the vagina and around, I will be describing how to do a warm sitz bath using salt. The laceration in and around the vagina might be sustained accidentally as the baby passes through the vagina or intentionally made by the midwife or obstetrician to widen the vagina opening for easy passage of the baby and this is called an episiotomy. After every delivery is completed, the vagina and the area around it is inspected for any laceration and stitched. If an episiotomy is given it is also stitched. The thread used for stitching can be damaged by heat resulting in opening of the wound which will require a second application of stitches. If you were stitched after delivery, do not let hot water get to the area. Yes, that’s what you just read, I know this is the opposite of what you thought or must have heard some folks say. If the bathing water is too hot, do not use it, you do not have to announce to the neighborhood when it is time for your bath as a result of very hot water being used.

CATEGORY OF WOMEN WHO MIGHT HAVE AN EPISIOTOMY

Episiotomy is a deliberate incision made on the vagina mucosa, perineal muscle and skin to widen the vagina to ease the passage of the baby. It’s more controlled compared to when the tear occurs accidentally as the baby is delivered which is more likely to be rugged and extensive. It is important to note that episiotomy is not routinely given until there is an indication for it. So, don’t be scared you might not need one however, the following category of women are more likely to have it;

• When the perineum is tight and threatening to tear
• Women with severe female genital cutting/female circumcision
• When the baby is big
• Previous scar that is threatening to tear
• Delivery of a baby coming with the buttocks
• When an instrument is to be used to assist the delivery example a vacuum or forceps

HOW TO PREPARE AND HAVE A SITZ BATH

To prepare a sitz bath, you need a lukewarm water in a receptacle either a bowl, bath tub or bidet. There are bowls that can fit on the toilet for this purpose or even electronic bidet that can be connected to the toilet. Add salt to the water until it becomes highly concentrated that the salt no longer dissolves easily as you add it to the water. Sit in it for about 15- 20 minutes 2 to 3 times a day. It should also be done after defecating. Ensure that the temperature of the water is comfortable enough for you and not hot as it will affect the stitches.

BENEFITS OF SITZ BATH

• It has a soothing effect
• It increases blood flow to the perineal region which helps with healing
• Helps to reduce swelling
• Helps to reduce pain
• It has an antiseptic effect
• Prevent infection at the site
• Keeps the area around the wound clean

WHO CAN USE A SITZ BATH?

Apart from women who just delivered, sitz bath can also be used in the following conditions;

• Hemorrhoids before or after it’s operated
• Bartholin’s cyst
• Anal surgery
• Vaginal surgery
• Vaginal infection

DOES IT HAVE A SIDE EFFECT?

It is rare to have any unpleasant effect from doing a sitz bath. However, one could rarely feel dizzy or the heart might be beating too fast. This might be as a result of an increased blood flow due to the dilation of the blood vessels caused by the warm water at the perineal region.

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