Introduction
WHO recommends exclusive breastfeeding for the first 6 months of life and breastfeeding with complementary feeding for the next one and a half year [1]. Breastfeeding decreases the morbidity and mortality owing to diarrhea and pneumonia, which are the main killers for infants and children younger than 5 years [23]. Additionally, breastfeeding reduces the likelihood of obesity and chronic diseases such as diabetes and hypertension [4]. Breastfeeding is good for mothers as well as babies. Indeed, breastfeeding has been shown to protect against postpartum hemorrhage, postpartum depression, ovarian and breast cancer, heart disease, and type 2 diabetes [5]. WHO recommendation for breastfeeding is a crucial and cost-effective way to help solve the dual burden of the nutritional transition in many low-income and middle-income countries. The dual burden is associated with malnutrition and micronutrient deficiencies [6].
Globally exclusive breastfeeding in the first 6 months of life is 39%, and after this age, only 58% continue breastfeeding up to 24 months of age [7]. Many factors influence breastfeeding, which cannot be stopped. Myths about breastfeeding are considered one of the main barriers for continuation of breastfeeding. Myths differ from one social class to another, from developed to developing world, and from country to country [8]. To increase the practice of breastfeeding among mothers, health workers should know how to deal with myths on scientific basis and how to deliver health message against them. In this article, the most common myths are discussed.
Myth 1: colostrum is not enough and not good
Colostrum is thick yellowish breast milk produced during the first few days after delivery. Its amount is small (30–100 mL/day) but sufficient for the first few days. It contains high content of protein, vitamin A, leukocytes, lactoferrin, and lysozyme. Colostrum has low content of fat and lactose. It has mild laxative effect, which helps to clear gut meconium. Moreover, it clears bilirubin from the gut and thereby helps to prevent jaundice [79].
Myth 2: small breasts give insufficient amount of milk
The size of the breast depends on the amount of fat not the milk-producing alveoli. The breast tissue that is needed to nurse an infant grows in response to pregnancy regardless of the mother's breast size. In fact, it is possible for mothers with smaller breasts to have a good supply of milk by understanding the needs of their infants and breastfeed as and when demanded to ensure adequate production of milk [10].
Myth 3: breast milk is dilute and not nourishing
Mature breast milk consists of foremilk (early in a feed) and hind milk (later in a feed). Foremilk is bluish-gray and watery, which provides plenty of water, protein, and lactose, whereas hind milk is whiter than foremilk and provides extra fat to achieve satiety. Moreover, the amount of fat in breast milk is not influenced by a mother's diet, even during fasting (e.g., during Ramadan). The amount of fat consumed by a breastfed baby in a 24-h period is also unrelated to how often the baby breastfeeds [9].
Myth 4: feeding on demand or at night may upset the gut
There are a lot of benefits to on-demand feeding. In the immediate days following birth, putting an infant to breast at any and all hunger cues is excellent for bringing in a full milk supply. Simply, the more breast stimulation, the better milk supply will be. On-demand feeding is also a good way to ensure that the infant will get enough milk to grow properly. Mothers have different storage capacities in their breasts, and all infants take in different amounts − even the same infant will take differing amounts throughout a day [11].
Prolactin is a hormone that helps build and maintain breast milk supply. In the early weeks of breastfeeding, prolactin receptors are being laid down in mother breasts to regulate the amount of milk which is needed to feed her infant. Prolactin levels rise with suckling; the more an infant nurses, the higher the prolactin levels. Prolactin levels are higher at night, and nursing at night helps to establish a strong milk supply for the duration of breastfeeding [12].
Myth 5: any expressed breast milk is immediately spoiled
Expression of breast milk is required in the following situations: feeding sick or low-birth-weight babies, to maintain milk production, to relief engorgement, and working mother. The expressed breast milk should be kept in clean tightly covered container. The storage is either at room temperature, up to 4 h, or in the refrigerator, up to 96 h. If milk needs to be warmed, it should be placed in a bowl of warm water [13].
Myth 6: breastfeeding has a bad cosmetic effect
Some women may notice a change in the shape of their breasts after breastfeeding, but pregnancy, not just nursing, is the culprit. The breast often doubles in weight during pregnancy, whether or not the mother breastfeeds. Any increase puts extra stress on the ligaments that support the breasts, and more stress equals extra sagging. Mother's age, BMI, and prepregnancy bra size all affect how likely breasts are to droop [10].
Myth 7: mother must eat special food to increase breast milk
A breastfeeding mother should eat a balanced diet, but there is absolutely no need to unnecessarily limit her diet or avoid certain foods. Diet should be nourishing with lot of fluids. Many societies have traditional foods and herbs for postpartum women that are meant to increase the mother's strength and enhance lactation. Some herbs mentioned as galactogogues include fenugreek, goat's rue, milk thistle (Silybum marianum), oats, dandelion, millet, seaweed, anise, basil, blessed thistle, fennel seeds, marshmallow, and many others. Most of them have not been scientifically evaluated [14].
Myth 8: stop breastfeeding if infant has diarrhea
Breastfeeding is the ideal feeding for a sick infant, as there are many factors within breast milk that protect his gastrointestinal system and fight off illness. Mother's breast milk also provides her infant with necessary fluids to prevent dehydration. WHO recommends breastfeeding with plans A and B for treatment of diarrhea [15].
Myth 9: mother cannot breastfeed for 24 h if she gets vaccine
If the infant is healthy, there is no reason to stop breastfeeding after getting any immunization. There is absolutely zero risk to the infant. The infant may benefit from the vaccine. However, mother has to be careful if the infant has an immune deficiency. If this is the case, mother should not receive any vaccinations that contain a live attenuated virus such as oral polio, or measles, mumps, or rubella [16].
Myth 10: breastfeeding is a reliable form of birth control
During the first 6 months of life if breastfeeding is exclusive day and night without any supplement, ovulation is inhibited and menstruation does not resume (lactation amenorrhea). In such situation, the risk of pregnancy is less than 2% [17].
Myth 11: formula is as good as breast milk
There are more than 100 different nutrients, hormones, enzymes, and disease-fighting compounds in human milk, all in perfect balance to meet a baby's needs. Although infant formula provides a nutritionally balanced food to encourage healthy growth, formula feeding can never compete with the many benefits of breastfeeding [9].
Myth 12: do not breastfeed after exercise
Some research has looked at the level of lactic acid (a by-product of high intensity exercise) in mothers’ breast milk after exercise. Although lactic acid can increase in breast milk following maximal exercise (exercising to the extreme of exercise intensity), mild or moderate exercise does not cause lactic acid to increase in breast milk and does not affect a baby taking the milk. As most mothers only wish to exercise to a moderate intensity to lose weight, and improve/maintain fitness and general well-being, most would say that maximal exercise is not relevant anyway. Regardless, there is no evidence to suggest that breast milk with increased lactic acid levels harms a baby in anyway [1819].
Myth 13: a reflux baby will do better on formula than breast milk
Regurgitation (gastro-esophageal reflux) is a common infant phenomenon. In a prospective evaluation of the natural evolution of regurgitation in healthy infants, regurgitation was highest in the first month, with 73% of infants experiencing it at least once per day, decreasing to 50% at 5 months of age. Infants regurgitating four or more times per day can often have difficulty with initial weight gain, although most issues are resolved by 12 months of age. However, ∼7% of infants experience severe reflux, requiring medical care [20]. Although the proportion of infants who experience reflux is similar among those who are breastfed and those who are formula fed, breastfed infants often have fewer and shorter episodes of reflux. Breastfed infants have more rapid gastric emptying, which can lower median pH values for gastro-esophageal reflux; therefore, a lower esophageal pH limits the duration of reflux [21].
Myth 14: if an infant has lactose intolerance, he/she needs to be weaned onto soy or lactose-free formula
It is extremely rare for an infant to be born with primary lactose intolerance. Even where there is a strong family history, lactose intolerance rarely develops before the age of 4 years. However, secondary lactose, a temporary condition following a bout of diarrhea, can occur in infancy. Breast milk has healing properties that will assist an infant's gastrointestinal tract to recover faster and should be encouraged [22]. Lactose overload (functional lactase deficiency), which is a relatively common condition for breastfed infants in the early weeks and months, is often misdiagnosed as lactose intolerance. Breastfeeding should be continued as gastric symptoms can be reduced with simple feeding management [23].
Myth 15: breast milk loses its nutritional value after X months/years
Breast milk continues to provide a valuable source of nutrition and immune protective factors for as long as a child breastfeeds. In fact, research shows that breastfeeding a toddler can provide 29% of his daily energy needs, 43% of his protein requirements, 75% of his vitamin A requirements and 60% of his vitamin C requirements. Mothers must be advised that breastfeeding is a biological norm. Science may not have proven every benefit thus far, but we are certain it is designed specifically for human babies [24].
Myth 16: breastfeeding is painful
Breastfeeding is usually easy. Although many mothers experience some nipple tenderness in the first 2 weeks, it is not normal for breastfeeding to be painful. After all, women have been doing this since the beginning of humanity. If the nipple pain does not subside or get better in 3–4 days and lasts beyond 5–6 days, then it should not be ignored. Mothers must get help as soon as possible from someone with the knowledge and experience [25].
Myth 17: mother must eat only bland foods while breastfeeding
Breastfeeding does not require a special diet. Most women can eat whatever they want. Food that is eaten will slightly alter the taste of mother's milk, which will prepare her baby for the family diet when it is time to introduce solids [26]. The most commonly restricted foods are caffeine, spicy foods, and raw foods. Common sources of caffeine are coffee, tea, and soft drinks. Although caffeine is transferred to breast milk, the amount of caffeine transferred to breast milk is generally less than 1% of the amount consumed by the mother [27], and modest caffeine use does not negatively affect infants [28]. It is common for mothers to be warned to avoid ‘gassy foods’ such as cabbage, cauliflower, and broccoli. Eating such foods can cause gas in the mother's bowel; however, gas and fiber do not pass into breast milk. Similarly, acidic foods like citrus fruits, pineapple, and tomatoes do not affect breast milk, as these foods do not change the pH of maternal plasma [29]. Many mothers do not eat spicy foods because these foods are thought to cause colic, gas, diarrhea, and rashes in the breastfeeding infant. However, although strong flavors such as garlic can change the smell and flavor of breast milk, this does not usually make infants fussier [26].
Myth 18: mother should not breastfeed if she smokes
Research has found that smokers are less likely to begin or persist with breastfeeding compared with nonsmokers. However, this is not thought to be owing to an inability to breastfeed but rather to do with the background of a mother who smokes [3031]. Some mothers who smoke believe that it is safer to give their baby formula rather than breastfeed. On the contrary, babies who are formula fed are more likely to experience the effects of second-hand cigarette smoke, compared with a breastfed baby. Breast milk contains important factors to help babies fight illness. Exposure to second-hand cigarette smoke increases a baby's risk of lung infections, asthma, and sudden infant death syndrome [30]. Breastfeeding helps protect the baby from these harmful effects of cigarette smoke [32].
Myth 19: irritable infant behavior is often due to low supply
Nearly every mother, at some stage, worries whether her baby is getting enough milk. When faced with difficult or irritable infant behavior, nursing mothers often worry that their milk supply has decreased. Where a breastfed baby is healthy and thriving, low supply is rarely the cause of irritability. Usually breastfed babies are weaned to an infant formula owing to a mistaken assumption that the baby's irritability is a sign of hunger. If this assumption is incorrect, irritability will not only persist while bottle feeding but the situation may become even more complicated by the many additional problems a bottle/formula-fed baby can face [11].
Myth 20: doctors know about breastfeeding
Occasionally a doctor may hold a special interest in breastfeeding and undertake additional education in this specialized area. However, very few doctors see this as relevant to their professional role. With some exceptions, doctors generally have very limited understanding of the practical aspects of helping a nursing mother to overcome breastfeeding difficulties. Sadly, it is often doctors who provide nursing mothers with misinformation regarding breastfeeding, which can lead to unnecessary weaning [33].
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgements
This project was supported by the Deanship of Scientific Research at Prince Sattam Bin Abdul Aziz University under the research project 41/H/33.
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