Not enough milk or not enough patience?
Optimal breastfeeding is so critical that it could save the lives of over 820 000 children under the age of 5 years each year. In particular, breastfeeding is the best preventive healthcare approach that developing countries can employ to reduce under-5 mortality.
The benefits of breastfeeding are beyond neonatal nutrition. Breast feeding is known to reduce the rates of respiratory infections and diarrheal episodes among children. It also reduces the risk of breast and ovarian cancer among mothers. These benefits have led to extensive research activities in breast milk and breastfeeding practices.
The volumes of colostrum have been quantified as 5 mL on first postnatal day and up to 25 mL on third postnatal day. The volumes may seem modest, but they are typically adequate, to meet the needs of their newborns.
However, ‘not enough milk’ is a common complaint in postnatal wards. It is a daunting task for the pediatrician and neonatologist to counsel the mothers that the volume of colostrum is sufficient for the newborn. The rate of maternal perception of ‘not enough milk’ can be as high as 50%, according to a large database of postnatal mothers.
The study showed that the mean and the median volumes of colostrum matched the traditionally defined volumes of colostrum. The mothers were given professional assistance by a certified lactation counsellor for timely and practical help during breast feeding. There was no significant difference in volumes of colostrum with respect to mode of delivery. However, a significant difference was observed among multiparous mothers who had a higher quantity of colostrum as compared with primiparous mothers. This was an anticipated finding.
Colostrum secreted in the first 2–3 days after delivery is initially produced in small amounts. The secretion of colostrum is typically around: 40–50 mL on the first day, equivalent to approximately 5 mL per feed. Subsequently, milk production increases, with larger amounts being produced between 2 and 4 days post-delivery, leading to a sensation of fullness in the breasts, commonly referred to as ‘milk coming in’. By the third day, an infant typically consumes about 300 mL per 24 hours, which equates to approximately 25 mL per feed. It is important to note that these data are derived from studies conducted approximately 20 years ago.
The present study showed that the mothers secreted comparable volumes of colostrum on postnatal days 1–3. Hence, the rising use of formula milk and the perception of ‘not enough milk’ may be a consequence of a lack of practical help and assistance from trained healthcare workers. Various studies have explored the average volume of colostrum and transitional milk in postnatal mothers on different days for different objectives. Nevertheless, a primary reason for lactation failure and the adoption of formula feeding is the maternal perception of ‘not enough milk’.
Further, the mode of delivery has been identified as another significant perceived barrier to successful exclusive breast feeding. A systematic review and meta-analysis revealed a negative correlation between prelabour caesarean delivery and early breastfeeding initiation. It is hypothesised that early initiation of breast feeding in the labour room or operation theatre within the present cohort could have facilitated comparable colostrum secretion among mothers. This may have happened irrespective of the mode of delivery.
A study by Bystrova et al showed that multiparous women are more likely to experience breast engorgement and give a higher number of feeds as compared with primiparous mothers, though there was no significant difference in milk volumes among the two groups. According to previous studies, the average feeding volumes for late preterm babies were suggested as 5–10 mL every 2–3 hours on the first day, 10–20 mL on day 2 and 20–30 mL on day 3.
The volumes of colostrum during the first 3 days of the postnatal phase were 4.7, 8.9 and 22.5 mL, respectively, aligning closely with traditionally defined volumes of colostrum from decades ago. Remarkably, these volumes remained consistent among the study cohort. This raises questions about the increasing use of formula feeding in perinatal settings. The study findings support the promotion of the Baby Friendly Hospital Initiative but require further affirmation through prospectively designed, risk-adjusted analyses.
