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The Department of Health (DH) and World Health Organization (WHO) recommend babies are exclusively breastfed for the first six months of life. Indeed, the WHO states it is now certain breastfeeding decreases childhood mortality and has benefits that extend into adulthood, and recommend that with appropriate complementary foods infants should continue to be breastfed up to two years. Breast milk provides all the energy and nutrients an infant needs for the first months of life and continues to provide up to half a childÕs nutritional needs during the second half of its first year, and up to a third during the second year.

In order to establish and sustain exclusive breastfeeding for six months, WHO and UNICEF recommend:

• initiation of breastfeeding within the first hour of life
• no additional food or drink, including water, is given
• the baby is fed on demand (ie as often as the child wants)
• bottles and pacifiers (dummies) are not used.

Milk production

Once the baby and placenta have been delivered, the levels of oestrogen and progesterone decline rapidly. Prolactin released from the pituitary gland stimulates the production of milk in the breasts, which are made up of adipose and secretory tissue. The fatty tissue supports and protects 15 to 25 lobes made up of individual alveoli, which produce milk and swell to hold it until required.

As well as prolactin, the pituitary gland releases oxytocin when the baby touches the breast, which stimulates contraction of the alveoli and forces milk into ducts that drain to the nipple. This is called the let-down reflex. Let-down may also occur when the mother hears her baby’s cry or when they think about the baby or feeding. Different women feel the let-down reflex in different ways. Some feel a slight tingling, some feel pressure and discomfort while others feel nothing at all.

For a few days after birth the breasts produce the first milk, which is called colostrum. This is a clear, yellow secretion that is rich in proteins, fats and minerals. It is the same fluid that may have leaked from the mother’s nipples during pregnancy. Colostrum is only produced in small amounts, and provides all the baby’s nutritional needs as well as containing high levels of maternal antibodies and lactoferrin, which has antimicrobial activity.

Mature breast milk begins to be produced around three days after birth, and the breasts start to fill. There are two types of breast milk. Foremilk is the first milk to come out of the breast at each feed. It is thin and watery, high in lactose and quenches the baby’s thirst. Hindmilk follows, which is thicker, rich in fat, more nutritious and satisfies the baby’s hunger. A baby needs both types of milk so it is recommended they feed fully from one breast before changing to the other.
Duration of feed varies, but during the first few weeks a baby should be fed around every two to four hours. Mothers should be advised to follow the baby and their individual needs. A breastfed baby cannot be overfed.

Mothers who worry their newborn isn’t getting enough milk may be reassured that as long as their baby is producing eight to 12 wet or soiled nappies over 24 hours, is passing soft, yellow stools, gaining weight and is calm between feeds, they are feeding well.

Problems associated with breastfeeding
Engorgement Most women experience some degree of breast engorgement when their milk comes within a few days of giving birth. The breasts become swollen and hard, may appear red and hot to touch and can feel very sore. With regular feeding the amount of milk produced adapts to the needs of the baby and this problem is usually resolved. On occasions when the mother is unable to feed her baby, such as when she is ill or during weaning, these symptoms may recur. Encouraging the baby to breastfeed on demand while properly positioned is the most effective method of treating and preventing engorgement, as well as most other feeding problems. Alternatively, engorgement may be relieved by expressing a small amount of milk by hand or with the aid of a breast pump.

Mastitis/blocked ducts It is common for breastfeeding mothers to experience blocked milk ducts at some point. A red, sore patch on the breast develops. Usually the blockage may be cleared by altering the position in which the baby feeds, creating a more satisfactory latch to draw properly from the breast. The mother should be advised to start each feed from the affected breast, as this is when the baby sucks hardest. Expressing some milk may also clear the blockage. A warm flannel or cold cabbage leaf inside the bra will ease discomfort and gently massaging the breast while feeding may also help.

In some cases the pool of milk behind the blockage may become infected and mastitis develops. Staphylococcus on the mother’s or baby’s skin enters a cracked or sore nipple and spreads into the breast tissues, causing a painful hot red patch and flu-like symptoms. If caught early treatment is with antibiotics such as co-amoxiclav or cephalexin. The mother should be encouraged to continue breastfeeding or expressing to relieve the pressure. Infections may lead to an abscess, which requires surgical drainage.

Sore/cracked nipples Many women find that their nipples feel sore when they first start breastfeeding. If they go on to bleed or crack, it usually indicates a problem with the latch. To achieve the correct latch the baby should take the whole of the nipple and most of the areola into its mouth.

Rubbing a few drops of breast milk or applying a smear of white soft paraffin or purified lanolin to the nipple aids healing. Paracetamol or ibuprofen may be safely recommended to ease discomfort but it is important the breast is still drained, either by feeding or expressing, to prevent engorgement.

Thrush Once breastfeeding is established any unusual nipple or breast pain may be caused by thrush infection. Thrush usually only affects the nipples, causing soreness and giving them a pink or red shiny appearance. In some cases it may spread into the breast along the milk ducts. This is known as ductal thrush and can cause deep pain within the breast, although it is common for the mother to experience no symptoms at all.

If thrush is present in the mother it is often present in the baby. Symptoms include a reluctance to feed and white spots in the mouth, which reveal a raw area if rubbed. Miconazole is the treatment of choice for both the mother and baby, who should be treated at the same time. Oral fluconazole is often prescribed in more severe infections but is not licensed for this indication.

Leaking breasts Many women find that milk leaks or sprays from their breasts when they are not feeding. This tends to occur when the breasts are full and may be brought on by the sight of a baby or hearing a baby’s cry. It can be an embarrassing problem which may lead to the mother giving up breastfeeding. Breast pads are available to place within the bra to absorb any leaks. They should be changed once they become damp to prevent the growth of bacteria.

Diet
Breastfeeding uses around 500 calories a day, which should come from a healthy balanced diet. The DH recommends breastfeeding mothers take a daily supplement of 10mcg of vitamin D. There are no foods that must be completely avoided while breastfeeding but it is advised that oily fish intake is limited to two portions a week and, as with all adults, no more than one portion of swordfish or shark be eaten a week (due to their high mercury content).

It is important to maintain a good fluid intake, although caffeine intake should be reduced as its presence in breast milk causes irritability in the baby. Alcohol also passes into breast milk, so it is recommended mothers stick to the same guidelines that exist for alcohol intake during pregnancy Ð no more than one or two units consumed once or twice a week.

Drugs
Nicotine is present in the breast milk of mothers who smoke, who should be advised to stop smoking. If the mother chooses to continue to smoke, she should be advised not to do so before a feed to reduce the babys exposure to nicotine.

Very little information is available on the safety of breastfeeding while taking medication. Most drugs pass into breast milk, but the majority of OTC and prescription medicines are considered to be compatible with breastfeeding. However, there are a number of drugs whose presence in milk is known to be harmful and whose use in breastfeeding is contraindicated. These include codeine, amiodarone, iv/oral chloramphenicol, long-term course tetracyclines, lithium, high dose vitamin D, aspirin and ginseng. Some drugs affect breastfeeding itself by inhibiting the infants sucking reflex, such as phenobarbital, or by affecting lactation, for example bromocriptine.

Drugs that are commonly used in infants or have a history of use in breastfeeding are a good choice. If a medication is deemed necessary but is contraindicated in breastfeeding, it may be possible to delay therapy or temporarily withhold breast milk. If absolutely necessary it may be advisable to stop breastfeeding.

Contraception
Many women believe that breastfeeding protects against pregnancy. The lactational amenorrhoea method (reliance on the absence of periods while breastfeeding as a form of contraception) is thought to be 98 to 99 per cent effective. However, this is only true if the baby is being breastfed on demand, without supplements or the use of a dummy and the baby is less than six months old. Its effectiveness is reduced beyond six months as weaning starts. To completely avoid the risk of conception additional use of condoms or a diaphragm may be recommended. The mother must also bear in mind that ovulation and therefore pregnancy may occur without first having a period.

As oestrogen suppresses lactation, combined oral contraceptives are contraindicated while breastfeeding. The progestogen-only pill may be used safely from three weeks post-delivery.

Stopping breastfeeding
There will come a time when the mother will wish to reduce or stop breastfeeding. If the mother is returning to work, it is not necessarily the case that breastfeeding has to end. By law, employers have to allow mothers time to breastfeed their baby, although this is not always practical. Breast pumps are available to express milk from the breast, which may then be fed to the infant via a bottle or cup. This enables the child to receive all the benefits that breast milk provides without the mother actually having to be present, and may be an option for women who need to be away from their child for short periods of time.

If it is decided to stop breastfeeding altogether, the baby should be changed to an appropriate formula milk, or cows milk if over 12 months. It is recommended breastfeeding is gradually reduced by dropping a feed every few days to reduce the risk of engorgement, with milk production ceasing completely within weeks.

Katharine Gascoigne is a part-time locum and pharmacy writer.

Other sources of information

• www.nhs.uk/Conditions/Breastfeeding
• www.nctpregnancyandbabycare.com
• www.laleche.org.uk
• www.babycentre.co.uk/baby/breastfeeding

References

• www.laleche.org.uk
• Regan, L. Your pregnancy week by week. London: Dorling Kindersley 2005.
• www.nhs.uk
• www.breastfeedingnetwork.org.uk

Reflect
How does the constitution of foremilk and hindmilk differ? What are the symptoms of mastitis? Which drugs are contraindicated for breastfeeding mums?

Plan
This article describes breastfeeding and includes information about milk production and common problems such as engorgement, mastitis, sore nipples and thrush. It also discusses diet, contraception and the safety of taking medication while breastfeeding.

Act

• Find out more about breastfeeding on the Clinical Knowledge Summaries website at http://tinyurl.com/breastfeeding01.
• Find out more about breastfeeding problems such sore nipples, mastitis and thrush from the NHS Choices website  http://tinyurl.com/breastfeeding02 and http://tinyurl.com/breastfeeding03.
• Read more about diet during breastfeeding and how some foods may affect the baby on the Babycentre website at http://tinyurl.com/breastfeeding04.
• Read the information about the safety of drugs in breastmilk on the Breastfeeding Network website at http://tinyurl.com/breastfeeding05. Print out any leaflets that may be useful for your patients.
• Revise your knowledge of contraception during breastfeeding on the CKS website at http://tinyurl.com/breastfeeding06.

Evaluate
Are you now familiar with breastfeeding and the problems that can occur? Could you give advice about sore nipples, mastitis and thrush? Could you advise about taking medication whilst breastfeeding?

Pharmacy is often the first port of call for women for healthcare advice, more so than for men, according to the results of last year’s Department of Health consumer research. The research also showed women will often visit the pharmacy not just for themselves, but for their partner’s and their children’s health.

“Compared to men, women tend to take a more active role in their health,” says Elaine Evers, pharmacy manager at Lichpharm Midcounties
Co-operative Pharmacy in Staffordshire. To build on that customer loyalty “community pharmacy must reinforce a caring image and ensure their customers recognise them as a one-stop shop for all their health and beauty needs”, advises Rob Jackson, UK pharmacy shopper based design manager for P&G PharmacyCare.

Pharmacists also need to be up to speed with the fast pace of change in women’s health products. Increasingly more medicines are becoming available without a prescription; for example, tranexamic acid is now available through pharmacies under the brand name Cyklo-F, for women with a history of regular heavy menstrual bleeding.

As well as being knowledgeable about the women’s products they sell, pharmacists should also offer further advice and information as appropriate, advises Ms Evers. “There’s a lot of confusion and misinformation about women’s health conditions out there, so pharmacists can help by giving evidence-based advice on treating or reducing symptoms of women’s health conditions, such as the menopause, or by checking that cystitis remedies are suitable for the individual patient.”

Pharmacists are also well placed to identify warning symptoms such as pain or bleeding after intercourse and to signpost women to the appropriate source of support, such as their GP or family planning clinic, says Boots pharmacist Angela Chalmers, who manages the multiple’s Holloway Road branch in London.

As well as focusing on symptoms and cures, Ms Chalmers stresses the importance of giving lifestyle advice to women. “It’s not just about offering tablets –  it’s about ‘how can I add to the quality of life of this woman through, say, advice about nutrition or by looking at their emotional wellbeing?

She adds: “As pharmacists we should never underestimate the power of giving customers good advice. The woman you spend time with who wants a discreet word about a condition will trust you and tell her friends.”

Mum‘s the word

Discretion is a key word for women’s healthcare, agrees Emma Charlesworth, Numark’s retail excellence manager. “Feminine health is sometimes a bit of a taboo subject, and is often seen as quite an embarrassing topic to discuss.

“Always remember that your customers may also be feeling this strain so remember to be discreet and compassionate.”

Women may feel embarrassed talking about common complaints such as thrush and cystitis, so Ms Chalmers advises pharmacists to promote the consultation room as a place where women can discuss these and other health issues in private and in confidence. Pharmacists should also ensure staff are trained to be discreet and to be empathetic with their customers so they understand what they are comfortable discussing, she believes.

“Some women are fine to ask for a combi thrush treatment over the counter, while others don’t particularly want to use the ‘T’ word, so you need to gauge what their needs are,” she says.

Pharmacies can also play a vital role in raising awareness about such sensitive conditions like cystitis. According to Angela Lloyd, marketing manager for Actavis UK which last month launched a digital and social media campaign for its cystitis brand Cymalon the condition is an “untapped market where consumers are dealing with it in different ways not realising that there is treatment out there”.

Many women expect pharmacies to stock specialist products to meet their needs, says Susan Woodhead, category insight controller at Lil-lets. “Within sanitary protection, this may mean those women with heavy periods, older women, women post-birth or mums seeking advice for daughters,” she says. Ms Chalmers stresses the importance of pharmacy having the right selection of all different flow types and of stocking big brand products that customers can buy while doing other medicines shopping.

Women’s categories, P&G’s Mr Jackson advises, should be located away from the men’s section to enable men and women to browse the relevant fixtures without embarrassment. Pharmacists may also want to create a women’s or beauty section, with associated categories, such as skin, hair cosmetics, feminine care and fertility, he suggests.