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The Need to Know on Breastfeeding

Madison Bova, Iqra Imran, Maria Tsarnas

Department of Nursing, Youngstown State University

NURS 3749: Nursing Research

Randi Heasley

June 19, 2022

The Need to Know on Breastfeeding

A woman’s pregnancy brings about a lot of healthcare related discussions with varying

findings and spectrums of viewpoints that revolve around formulating the most beneficial and

appropriate outcomes for both the mother and baby. One of these topics is breastfeeding. Most

commonly, the advantages of breastfeeding and very rarely, the disadvantages of it are widely

addressed and documented. Although it is important to be aware of the benefits to breastfeeding,

it is equally significant to learn the factors that affect breastfeeding, which can potentially affect

breastmilk and the health of the baby. Some of these factors are nutrition, maternal stress,

latching, perception of inadequate milk supply, and infant abnormalities. This review study aims

to not only emphasize the correlation of those stated factors and their individual importance, but

also provide patient education to enhance the knowledge of parents.

Most of the study reports utilized in this report were descriptive and experimental design

research. For the purpose of this research report, different search strategies were applied to find

the appropriate articles to fit the subject matter. The search engines Medline and CINAHL were

of use. Terms such as breastfeeding or lactation or breastmilk, pregnancy or pregnant or

maternal, latching, stimulation, nutrition or diet, stress levels, abnormalities, congenital heart

defect, Downs Syndrome, cleft lip and palate, and patient education assisted the search. Filters

such as peer reviewed, publication date within the last five years, and English language also

facilitated the process. For one of the themes included in this report, the search yielded about

20,000 articles. This was further narrowed down by clicking on individual articles that aligned

with the narrative of each of our respective subtopics of this report. The result was usually

around 200-19,000 but the articles that were utilized were found on the first couple pages.
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Essentially, seven articles were used in total to complete this literature review. The PICO(T)

question that this study is based on is how effective patient education on breastfeeding for

pregnant women is compared to those who do not receive this education. The research work

exploited in this literature review facilitates broadening the knowledge on breastfeeding to better

improve patient outcomes for the lactating mothers and their babies.

Nutrition

It is no secret that one of the main reasons for mothers to consider breastfeeding is for the

purpose of nutrition, which therefore affects the health of the baby. Breastmilk nutrients are

incomparable to any other first food the baby can receive. Nutrition relates to the immune

system, meaning incorporating breastmilk in the baby’s diet is going to strengthen his or her

immunity and protect against allergies, sickness, diseases, and infections. In order to produce

milk of adequate quality and quantity of nutritional status, the mother’s intake of nutrition must

be appropriate. An experimental study done to determine the effect of increased consumption of

sugar and fat on breastmilk composition found that consuming a diet higher in sugar and/or fat

compared to the control group resulted in greater breastmilk TGL concentration. The high sugar

diet showed 13.8g/dL in TGLs, while the high fat showed 10.7g/dL. In terms of cholesterol

concentrations, the high sugar diet increased to a greater degree than both the control and high

fat diet. Since triglycerides and cholesterol are major necessary components of breastmilk, these

findings propose that those concentrations are easily influenced by minor varying changes in the

maternal diet. (Ward et al., 2021)

To promote nutritional intake for mothers during period of lactation, it is important to

provide the best recommendations that will guide them to manage their health and the

composition of breastmilk. A descriptive article based on the awareness of breastfeeding noted,

“Recommendations for micro and macronutrient intake in lactating women is higher than in

pregnant women.” (Krbavčić et al., 2021) Some examples of nutrients with corresponding

recommended intake levels are presented in this article. For example, DRI based carbohydrates

to 210g/day. It also stated that the fiber intake should be 29g/day. The article reported lactating

mothers to include 71 g/day of protein. Water is an essential necessity no matter whether

breastfeeding is in question, but for lactation purposes, it should be 3.8L/day. The article further

supported the intake of amino acids, vitamins, and minerals, each with their corresponding

values depending on the type. If there is a potential deficit for any of the nutrients previously

discussed, micro or macronutrients, dietary supplements can be prescribed. “Women who are

breastfeeding multiple infants should consider supplementation with magnesium and calcium

due to the increased production of milk.” (Krbavčić et al., 2021) Since lactation raises nutrient

needs due to the loss of nutrients that is going towards the breastmilk, it is crucial for

breastfeeding mothers to be highly aware of their diet and make choices that will be beneficial.

Stress levels

Pregnancy alters many aspects, such as hormones, physical and psychological changes

due to new roles and responsibilities, and distress. A study aimed at learning the relationship

between maternal stress and immunological components of breastmilk assessed slgA

concentration in breast milk and used the Hung Postpartum Stress Scale (HUNG-PSS),

Perceived Stress Scale (PSS), and Positive and Negative Affectivity Scale to form results. “A

negative association was found between the postpartum-specific stress total score and milk slgA

concentration, with increased postpartum stress being associated to reduced slgA concentration

in breastmilk.” (Segura-Pérez et al., 2022) Secretory immunoglobulin A is the main antibody

found in breastmilk that assists the immune system and growth, so this decrease is not healthy.
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Cortisol levels were only associated with postpartum specific stress and not with general stress.”

(Segura-Pérez et al., 2022) When anyone experiences stress, the body responds by releasing

cortisol which can help to cope in the short-term but may have a negative effect in the long-run.

Stress is inevitable with pregnancies and breastfeeding, though it is always possible to manage it.

Infant abnormalities

In nursing school, part of the curriculum, especially for classes like pathophysiology and

OB, is to teach about birth defects and how they can affect patient's long term. Knowing about

any type of infant abnormality is beneficial to nurses to improve their quality of care. In relation

to this specific research topic, there are three infant abnormalities that strongly affect the breast

lactation and the feeding process. The three abnormalities are cleft lip/palate, congenital heart

defects, and down syndrome.

Cleft lip is the most common craniofacial birth defect and the second most common birth

defect. Infants with cleft lip/palate have a tough time creating the suction necessary for

successful breastfeeding. One of the underlying (and unknown) causes of orofacial clefts is colic

acid deficiency. Deficiency in folic acid causes DNA damage which can lead to stem cell

mutations that may end up affecting future generations. Cleft lip and palate are an example of a

condition that often results from this type of genetic mutation. “Early identification and action

towards folic acid deficiency can aid in the management and prevention of cleft lip and palate”

(Brooklyin, et al.,2014).

Despite the benefits of folic acid supplementation, there is no guarantee it will truly solve

the problem infants with cleft lip/palate have with breastfeeding. Surgical repair is the most

beneficial solution to the problem. Many parents are skeptical about surgical repair due to a few

factors, a couple of the most common are: the general risk of an infant undergoing surgery, and
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the cost. A study done between June 2009-March 2012 highlights the benefits surgical repair has

for breastfeeding and lactation. “All 23 mothers in the study had improved lactation after

surgical repair of their infants and the infants were also able to suck better. This resulted in

improved nutrition for the baby as well as a better emotional bond between the mother and child”

(Mzezewa, et al).

Aside from cleft lip, down syndrome is another condition making it difficult for infants to

properly latch during breastfeeding. “A relatively large tongue, hypotonia and atypical oro-motor

development can contribute to speech and feeding difficulties with disorganized and

dysfunctional sucking patterns reported. For infants and children with Down syndrome, the

incidence of pharyngeal dysphagia and oral dysphagia is as high as 58 and 64% respectively”

(Coentro, et al.,2020). The protruding tongue makes it exceptionally difficult to latch because it

can push up against the nipple of the mother. Aside from the difficulty latching, children with

down syndrome are generally more prone to ear infections so it is important to breastfeed with

the baby in the most upright position possible. This may make the feeding process more difficult

for the mother if she is unable to maintain a comfortable position.

The third most common abnormality infants are born with affecting breastfeeding/milk

production is congenital heart disease. As with any chronic illness, the body's energy

requirements for CHD are increased, the heart must work harder to deliver oxygen throughout

the body. This makes it more difficult for the body to maintain adequate nutrition. “Many infants

with CHD die within the first year of life. Most of the time one of the underlying causes is poor

nutrition” (Tandberg, et al). Also, fluid backup in the lungs can make it difficult for the baby to

breathe, thus creating difficulty during the sucking process. Infants suffering from CHD often

have to undergo cardiac surgery which more often than not leads to decreased GI, renal, and
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oropharyngeal function. A study focusing on the effects of oral stimulation on breast milk

production and feeding done by an infant rehabilitation doctor shows the benefits of oral

exercises on a post operative infant. “The doctor performed 10 minutes of oral stimulation with

breast milk or physiological saline followed by two minutes of stimulation with the mother's

nipple on the infant. Through this early oral stimulation, the mothers experienced increased

lactation and infants experienced faster GI function recovery and a shorter stay in the hospital”

(Yu, et al).

Latching

As previously stated, breast milk provides the most nutrition, such as; vitamins and

proteins. It also contains important antibodies and helps reduce the risk for disease in babies.

There are numerous factors about breastfeeding that many mothers are not educated on before

having their baby. One factor being the correct position of the baby to latch on. Having the

correct positioning of the baby would provide an adequate amount of milk for the baby and can

be less painful for the mother. The position of breastfeeding is the most important part of

breastfeeding for the baby and the mother. Inappropriate positioning can negatively affect the

mother and lead to the cessation of breastfeeding early in the baby’s life. Education on the

correct positioning and latching can lead to a decrease in nipple pain and an increase duration of

breastfeeding.

The purpose of this article was to evaluate the effectiveness of the laid-back

breastfeeding position to help decrease nipple pain and trauma, thus increasing the length of time

of the mother breastfeeding all through evidence-based practice. In this study, the laid-back

breastfeeding position refers to the mother in a semi-reclined position while the baby lies on the

stomach tilted up. The terms biological nurturing (BN) and laid-back breastfeeding (LBBF) are
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interchangeable. “According to a study [6], approximately 70.3% of mothers suffered from

breastfeeding difficulties, including cracked nipples, the perception of an insufficient amount of

milk, pain, and fatigue. It is estimated that 80–90% of mothers experience nipple pain [7], and

58% of them experience nipple damage [8]” (Wang et al., 2021.) As demonstrated by these

statistics, there are many factors that lead to the abandonment of breastfeeding prematurely.

Four studies showed that nipple cracks were the most common nipple trauma. The laid-

back position could reduce the nipple cracks rather than the traditional position. This study

indicated that the experimental group had a lower occurrence of nipple trauma and nipple pain

compared to the control group. “A qualitative analysis to identify breastfeeding barriers in the

early postpartum period found that the most common barrier was the mother’s perception of an

inadequate milk supply and difficulty with latching” (Wang et al., 2021.) Latching may be the

first common mistake mothers have when breastfeeding, however, inadequate milk supply is also

a common misconception.

Perception of inadequate milk supply

The most frequently reported reason for the cessation of breastfeeding is due to the

complaint of not having enough milk supply, which in this article is also referred to as self‐

reported insufficient milk (SRIM). Many mothers struggle with self-efficacy when it comes to

becoming a mother and breastfeeding. A mother’s self-assessment on her milk supply was done

in this article and determined that the concern for their baby’s satisfaction was based on crying

and fussing. “We documented a relationship of maternal breastfeeding self‐efficacy with a

reduced risk of SRIM and longer breastfeeding duration. Hence, it is important for breastfeeding

counseling programs to prepare women from pregnancy and the early postpartum period by

building their confidence toward establishing an ample milk supply to nourish their infants”
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(Segura-Pérez et al., 2022.) Education programs for mothers would be greatly beneficial to

improve their knowledge on breastfeeding and everything that comes with it.

Mothers have a lack of information on what to expect during the colostrum phase, which

in this article is also referred to as delayed onset of lactation (DOL). The colostrum phase is the

first phase of breast milk that occurs while the mother is pregnant and just after birth lasting two

to four days before it continues into the other two phases. This phase is often mistaken and

reported as self‐reported insufficient milk (SRIM) because this milk is quite different than what

one would expect if uneducated. Colostrum milk is thick, deep yellow, is nutrient-dense filled

and high in antibodies and antioxidants to build the newborns immune system. “On average,

SRIM was reported by 44.8% of women for introducing commercial milk formulas (CMF)

(range: 10.5%–73.1%) and 33.8% of women for stopping breastfeeding (10.0%–74.2%) (Table

3). Furthermore, 28.9% of women reported DOL (Table 4)" (Segura-Pérez et al., 2022.) Based

on these studies, it is found to be that there are many women who are able to produce an

adequate amount of breastmilk, they just aren’t given the resources or educational tools to help

them fully understand the phases of breastfeeding.

Patient education

In terms of patient education, there are general and specific things a nurse can educate

their patient on. The best way to encourage breastfeeding and proper breastfeeding techniques is

to educate mothers on the benefits of breastfeeding. Colostrum, which is the first milk that comes

from the mothers' breast, is remarkably high in antibodies, and as the mother continues to

breastfeed the milk continues to have antibodies. Breast milk and colostrum also contain

immunoglobulins IgA, IgM, and IgG. These immunoglobulins along with the antibodies

strengthen the infant's immune system and provide a head start for fighting infections,
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specifically ones the mother had in the past. Breast milk is also known to significantly decrease

the risk for many common childhood illnesses like asthma and ear infections.

A study conducted at BMC women’s health showed 40 percent of the mothers in the

study had issues with breastfeeding. The results from 15 days (about 2 weeks) postpartum

revealed 40 percent of the infant related issues were due to incorrect position during sucking and

38 percent of mother related issues were due to fissures and nipple pain. Factors associated with

these problems included the mother's first pregnancy, low self-efficacy, and the mother's

knowledge on breastfeeding. Results from six months postpartum reveal 61 percent of mothers

used an incorrect breastfeeding method and 52 percent of the babies were not latching. “After

being educated on proper breastfeeding methods and the use of a breast pump, the mothers and

babies showed improvement with breastfeeding” (Shafaei, et al., 2020).

For infants with issues such as down syndrome, cleft lip or palate, and congenital heart

disease, it is understandably more difficult to breastfeed. Babies with cleft lip or palate and down

syndrome have a particularly challenging time with latching and sucking. Proper latching

techniques are highly beneficial to these mothers. “Such techniques include expressing some

milk on the nipple before feeding to encourage latching and ensuring the baby gets a large

mouthful of breast tissue to help stimulate the breast” (Coentro, et al.,2020). For babies with

congenital heart disease, it is important for the mother to know she can consult with her baby's

doctor or a nutritionist to figure out how much milk the baby should receive due to their

increased calorie requirements. Oftentimes, these babies need a very specific amount of breast

milk and may need supplements added to the breast milk to prevent malnutrition and maintain a

healthy weight for the baby.

Nurses should make every effort to know about breastfeeding so they can be prepared to

educate a patient if needed. Nurses working in fields like OB, pediatrics, and even family

practice, should especially be well versed on the benefits of breastfeeding and proper techniques

for all babies and those with conditions that may impair the breastfeeding process. Educating

patients on this information as well as education on living a healthy lifestyle will increase the

likelihood of a healthy baby and decrease the risk for complications associated with

breastfeeding. Overall, patient education is beneficial for not only mothers, but all women

planning to become mothers.

Conclusion

The articles and studies included in this report contribute to the growing knowledge of

several factors that affect breastfeeding. The factors included in this report are nutrition, stress

effects, latching, perception of inadequate milk supply, infant abnormalities, and patient

education. From the thorough research that the report explains, it is shown how stress and

maternal nutrition affect the breastfeeding process as well as providing education on the latching

process and how it may differ for infants with certain health conditions. In addition, it also

provides evidence of the most high-risk conditions affecting breastfeeding which are down

syndrome, orofacial clefts, and congenital heart disease. In conclusion, the research includes

educational information on not only the several micro topics discussed, but also how to properly

breastfeed infants. This information can help nurses and nursing students better prepare their

patients for an extremely vital part of motherhood.

References

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acid and DNA damage in cleft lip and cleft palate. Clinics & Practice, 4(1), 4–6.

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Chen, P., Johnson, L., & Rosenthal, M. (2012). Sources of Education About Breastfeeding and

Breast Pump Use: What Effect do they Have on Breastfeeding Duration? An Analysis of

the Infant Feeding Practices Survey II. Maternal & Child Health Journal, 16(7), 1421–

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