Guidelines for Mothers : by Wendy Nicholson OAM, RN RM LACTATION CONSULTANT 

 Introduction: Most women have breast reduction operations (reduction mammaplasty) because of the physical problems caused by abnormally large breasts. The relief experienced after the operation is universal, and most women are very satisfied with the outcome - they can exercise, buy `normal' clothes, and they no longer have backache and other problems.
The question of breastfeeding after a reduction operation may or may not have been explored. We assume that you would like to breastfeed your baby if you can. In these Guidelines, we hope to answer most of the questions that you may have thought of, and provide you with information that will assist you and your baby.

Surgeon's Advice:The question of the possibility of future breastfeeding may or may not have come up during pre-operative discussion with your surgeon. The most common types of operations are designed to preserve at least part of the lactation function of the breasts. So most surgeons will advise that breastfeeding may be possible, but that there are no guarantees.
Sometimes the surgeon may find it necessary to completely sever the nipple (e.g. when operating on the largest breasts). The surgeon will then usually advise that breastfeeding will not be possible.

The Possibility of Breastfeeding: From our experience, it can be said that the vast majority of women who have had breast reduction operations can breastfeed, although only a few will be able to exclusively breastfeed. Combining breastfeeding with formula supplements is the most likely outcome. The woman can fulfil her wish to give her baby the best start while at the same time ensuring the baby gets adequate food for growth and development. Even partial breastfeeding confers great benefits for the baby - the immunological and anti-infective properties of breastmilk, as well as the perfectly balanced nutrients. The closeness and contact between mother and baby benefits them both.
It is also our experience that some women who have been advised by their surgeon that breastfeeding will not be possible can still produce breastmilk. It may be that the cut milk ducts join up again. So regardless of advice it is certainly worth trying to breastfeed.
A very small number of mothers will try breastfeeding but find that it is not working - there are few or no ducts connected, and so the milk being made in the breast cannot be drawn out. The consolation for these few women is that they gave their breasts a chance, and there is nothing to be lost by trying.

 Antenatal Advice: During pregnancy, it is a good idea for you to gain as much knowledge about breastfeeding as possible. This will assist you when you have your baby and start breastfeeding. Attending Parent Education classes, reading books (see list at the end) will ensure you get a good basic knowledge.
There is no need to prepare your nipples - general advice is to avoid using soap which can be drying. After about 20 weeks or so you may be able to express colostrum. (If you are not sure how to try expressing, ask the midwife at your antenatal visit to show you how.) However, if you cannot express colostrum, this does not mean that you will not be able to breastfeed. The only true test will be when you attempt breastfeeding. 

Starting Breastfeeding:It is important to have a good start to breastfeeding, to give your breasts a chance to demonstrate their capabilities. 

1. The first breastfeed. The baby is usually in an alert state for the first few hours after birth, and this is the ideal time to start breastfeeding. The baby will usually give you indications that he is ready to suckle - first the eyes open, and the baby makes mouthing movements, and sucks on his fingers. Then he starts `seeking' the breast, and this is the time to offer him the breast. You may need assistance from the midwife to get yourself in a comfortable and suitable position to feed. The first breastfeeding at this time will help ensure that the baby gets the idea of suckling, as well as being the perfect stimulus to milk production. 

2. Correct positioning at the breast and correct `latch on': If the baby is on the breast properly, he will be able to suckle and obtain the colostrum - the first milk - efficiently, wiithout cauusing any nipple pain. 

3. Unrestricted feedings: It is vitally important that you feed the baby when he indicates that he is hungry, and to feed him until he comes off the breast of his own accord. Both breasts should be offered at each feed, and in the first few days at least, he will usually take both. Frequent feeds are the excellent stimulus for your breasts, and will quickly enable an evaluation of the situation. 

4. No forumla for at least the first 24-48 hours: To `test' your breasts capabilities, it is important not to give the baby any breast milk substitutes; this includes water and formula. It is also a good idea to not use a dummy, because this can stifle the baby's desire to suckle. 

Progress Assessment: The functioning of the breasts can be assessed in the following ways:
1. Is the colostrum/breast milk coming through the ducts, and out the nipple?
This can be assessed by expressing your breasts, and by observing the baby on the breast. If the sucking is slow and rhythmic, with deep jaw movements, and the swallow `click' is heard, then the baby is getting milk. The baby will also usually be contented after a feed when he is getting colostrum/breastmilk adequately.

2. Is the `let-down' reflex working?
Only some women experience a tingling feeling in the breast when the milk lets down. But most women experience `after pains' when they are feeding. These are pains (rather like period pains or small contractions) caused by the hormone oxytocin which makes the muscles of the uterus contract. Oxytocin also causes the muscles around the milk-making cells to contract, thus pushing the milk down the duct system. This will occur whether you feel anything or not.

3. Is the baby getting colostrum/breastmilk?
Normally the baby does not get large quantities of colostrum. But his behaviour will tell you that he is reasonably contented. It is normal for breastfed babies to need frequent feeds (2-3 hourly) especially in the first few days. 
Once the full milk starts coming in, the baby will get increasingly large quantities of breastmilk. At this time, he will start passing more urine, and the stools will change from the first blackish meconium stools to the frequent, runny yellow breastmilk stools. These signs tell you that your breastmilk is passing through the baby's digestive tract.
When the full milk starts coming in, your breasts will firm up, and you may have some engorgement. If there are some hard lumps that do not soften when the baby has fed, this may indicate some areas of the glandular tissue which do not have a connection to the nipple ducts. This should not be of concern - these areas of the breast will gradually cease making milk and settle down in a few days.

4. Is the baby getting enough breastmilk?
The baby's weight will give a strong indication about how your breasts are working, after the initial weight loss. It is normal for babies to lose up to 10% of their birth weight in the first 2-4 days. After the full milk has started coming in on Day 2-3, they usually start gaining weight.
Obviously the baby should be breastfeeding well and frequently enough to stimulate the breasts, as described above. If there is lack of weight gain, breastfeeding techniques and frequency should be reviewed carefully. If these are definitely correct, only then can we conclude that your lactation is insufficient.
A full milk supply is not usually reached for several weeks, and by 6 weeks the adequacy of milk supply will be demonstrated.

5. What can you do if you have insufficient breastmilk?
If the baby fails to start gaining weight or later fails to maintain an adequate weight gain, then partial supplementary feeding must be started. There are many women who successfully combine breastfeeding with supplementary feeding, and continue in this way for many months.
Supplements are usually given after the breastfeed. Some mothers find they only have to give one or two small supplements a day. Other mothers find they need to give one after every breastfeed. It depends on your breast milk production. Mothers usually find they plateau-out at a certain level of supplements.
The method of giving supplements: During the first week or so, one big disadvantage of using bottles is that some babies may not be well `established' with their breast sucking action, which is different to sucking on a bottle teat. This `sucking confusion' may cause the baby to fuss at the breast or start rejecting the breast; however this is a very individual thing and many babies will take both breast and bottle without any problems. But to avoid this potential problem, supplements can easily be given to the baby by cup.

 Cup Feeding: Babies learn to cup feed quickly, and will open their mouths in readiness for the cup. Any small cup with a smooth lip or edge will be suitable e.g. a medicine measure. The baby is held in a semi-upright position, with his hands gently restrained. Rest the cup on the baby's lower lip, and dribble the milk just into the front of the baby's mouth. The baby will soon learn to lap or suck the milk. He may push some of the milk back out with his tongue, so the cup is kept resting on the lip to ensure no milk is wasted. Allow pauses as the baby needs them - let him `control' the feed. Avoid a `tidal wave' of milk into the baby's mouth, as this may cause him to cough and splutter. After a few feeds, the baby usually becomes quite speedy at cup feeding.
If you start giving supplements after a few weeks, the baby is usually well established with his breastfeeding and bottles are usually no problem.

Use of a Supply Line: Another way to overcome or avoid sucking confusion is to give supplements by a Supply Line (or Supplementary Nursing System). This uses a fine tubing which is taped next to the nipple, and comes from a plastic container of milk hung around the neck. As the baby sucks on the breast, he also gets formula through the tubing. The main disadvantage of this method is that it is a bit fiddly to use (although mothers who have used it say they soon get used to it), and it requires careful cleaning.

Advantages For The Mother: Some people may suggest that if you need to start supplementary feeds, you might as well change over to the formula completely. However, apart from the benefits to the baby of receiving your breastmilk, and the close contact of breastfeeding, they are not considering the benefits to you of continuing partial breastfeeding.

There are many advantages for the mother: think about some of the following.

 Many mothers find that the night feeds can often be breastfeeds only, which saves having to get up to prepare formula. Many mothers, especially when they are very tired, just take the baby into bed with them, put them on the breast, and go back to sleep. On the other hand, your partner can give you a `break' and give a bottle, letting you sleep.

When you go out for a short time, you may find that you don't need to take bottles - if the baby does happen to need a feed, thhe breastfeed will usually be adequate to keep him happy until you get home.

If a baby has a cold or some other minor ailment, he is so easily comforted by breastfeeding. And breastmilk is particularly suitable for the unwell baby!

 The other advantage of continuing breastfeeding, which is often not mentioned, is financial savings. Formula and its preparation cost money, and most people appreciate at least a partial saving in this area! 

Support and Advice: Decisions about your progress with breastfeeding are ultimately yours. Health professionals and others will advise you, give their opinions, but you are the `boss' - it is your baby. You will do what is best for your baby and yourself. 

Advice can be obtained from the midwives in hospital and the lactation consultant. After discharge, you may have the Domiciliary midwife visit you for some days at your home. Then the Maternal and Child Health Nurse will be your main health support person.

Many women find they gain great support and practical encouragement from the mother-to-mother support of the Nursing Mothers' Association of Australia (NMAA). One does not have to be a member to ask them for advice. However membership has definite advantages - not the least a delightful Newsletter, with many interesting articles and information in it.


Nursing Mothers' Association of Australia. (03) 9885 0855.

* Lactation Resource Centre, NMAA (as above). An expert resource centre.

Reading List

If you are a `book' person, there are many good books about breastfeeding that you may be interested in. These are a few suggestions:

Bestfeeding: Getting Breastfeeding Right for You By Mary Renfrew, Chloe Fisher & Suzanne Arms. 

Celestial Arts. About $26. An excellent book with detailed practical advice (and terrific illustrations) about how to get the baby on the breast right, and many other really practical suggestions. Midwives, Mothers & Breastfeeding By Wendy Nicholson:
    NMAA, 2nd Edition 1991. $6.95. Many mothers find this small book very helpful and practical when first starting breastfeeding 
Breastfeeding: A new mother's handbook by Hilary Tupling.
    Watermark Press. About $15. An excellent book by a NSW psychologist who is also a mother. It has good breastfeeding advice, and excellent suggestions for coping with the stresses and pressures that many new mothers experience.
Breastfeeding ....Naturally. Edited Jane Cafarella. NMAA. 1996
    $23.95. Covers all aspects of breastfeeding.
 NMAA booklets Available from NMAA. $3.50 each. The booklets cover all the various aspects of breastfeeding and different problems that women might encounter. One booklet is about adoptive breastfeeding and relactation, and contains practical advice about how to use a Supply Line. NMAA Newsletter Articles:
The following articles may be of interest: `Breastfeeding after breast reduction surgery' by C Jarvis.

NMAA Newsletter Sept. 1987: p 14-14
 `Breast surgery and subsequent lactation'

Letter, NMAA Newsletter Aug. 1982: p 22-25
`Breastfeeding with the use of a supply line' by F Sutherland

NMAA Newsletter May 1987: p 24-25

Promoting Breastfeeding: Victorian Breastfeeding Guidelines Revised edition 1996

 These Guidelines are published by Health & Community Services, and provide both health professionals and women detailed suggestions for the start of breastfeeding. This includes policies hospitals should adopt to support and protect breastfeeding. It can be obtained free from Health & Community Services Victoria. 

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First put on the web on 27 Jan 1998

Revised 12 JUNE  2006


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