In western society we know that for myriad reasons women often cannot achieve optimal breastfeeding, which leads to giving up, topping up with formula and early weaning. With this in mind, Prof Diane Spatz, professor of perinatal nursing at the University of Pennsylvania in Philadelphia and a nurse researcher and director of the lactation programme at Children’s Hospital Philadelphia, believes that healthcare professionals must ask how they can proactively mitigate this to help mothers achieve full milk production so that they can meet their breastfeeding goals. 

Prof Spatz, who was speaking at Medela’s Breastfeeding and Lactation Symposium held in London earlier this year, said that there is a critical window of opportunity to establish milk supply.

“What we know from a research standpoint is that the first hour after birth is crucial. We know that the first day, the first two days, the first three to five days, really set the stage for long-term milk production. 

“Unfortunately, with current birth hospital practices, the way in which women give birth, with very interventional deliveries and what occurs during the hospital stay, the quote, ‘normal lactation experience’ doesn’t usually occur for most mother-baby dyads,” she said.

Given the evidence, Prof Spatz said that it is clear that healthcare professionals need to change the current practice paradigm to ensure that women and their families, firstly, are able to make an informed feeding decision and, secondly, are able to effectively establish and maintain a robust milk supply. 

She believes that this must start with antenatal education in order to create a sense of empowerment about breastfeeding and a sense of urgency about milk supply. She said that during antenatal care, women and their families need to be educated that all pregnant women, no matter at what gestational age they deliver, will be producing milk (lactogenesis). They should be educated on the physiology of milk production and the critical window after birth that sets the stage for the mother to come to full volume. 

Risk factors

Prof Spatz emphasised that it was critical during pregnancy to identify any potential risk factors that could impact the mother’s ability to reach full milk volume. Such risks included glandular hypoplasia or breast surgery. Further, she said it was also crucial to identify potential risk factors that could delay lactogenesis II (secretory activation) such as, primigravida, obesity, hypertension, diabetes and maternal age over 30 – all prevalent in the Irish setting – to name a few. 

“If the mother has risk factors, she should be informed prior to delivery. Strategies should be presented to optimise her breastfeeding journey; these include antenatal expression of colostrum, using pasteurised donor breastmilk as a bridge until milk supply comes to volume, and to pump early and pump often after delivery.

Prof Spatz says that these steps are not taken often enough to help those mothers at risk. She said that in hospital following the birth many health professionals do not have a sense of urgency about ensuring the mother effectively converts from lactogenesis I to lactogenesis II and that many routine hospital practices negatively affected the mother’s ability “to come to volume”. These practices, she said, included inductions, the lack of rooming in, lack of skin to skin, concerns about infant weight loss and formula supplementation from birth. 

“If a baby is healthy and can breastfeed, that baby should be breastfed within the first hour, We know that this doesn’t happen globally. If the baby is unable to feed before a good rest, then we need that mother to be expressing with a pump with initiation technology within that first hour. What we want families to understand is that there’s a critical window of opportunity. This is time sensitive. There’s a set period of time, where we have to really focus on milk supply,” she said.

Prof Spatz argued that if this critical window to establish milk supply postpartum was understood and observed more widely, the beneficial effect would be widespead.

“Mom’s only job when her baby is home with her is that she eats, sleeps and breastfeeds. If we really protected that critical window of opportunity for mothers and focused on the supply, we would probably solve a lot of the world’s breastfeeding problems,” she said.

Prof Spatz said that research shows that globally the number one concern of mothers is milk supply and that it was common for infants in hospitals around the world to be supplemented with formula. This means that they are not going to wake on cue to feed, so  the breasts aren’t stimulated and milk supply will spiral downward.

She said she would love to see mothers with risk factors adding expression sessions with a hospital-grade pump.

“My message is if you’re going to say the word ‘supplement’, then you need to say the ‘P word’ which is pump. We must change the practice paradigm, so that all women have the opportunity to reach their personal breastfeeding goals,” she said.