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3.7 Weaning

Key Points - Case Study C

Joanne is discharged early on day three and comes to see you for follow-up on day five. The day following discharge her breasts became painful and hard and Rosie is again having difficulty latching on to the breast. Is this normal? What would you suggest Joanne do?
Topic 3.1: Early problems
There is a difference between breast fullness and engorgement. Early frequent feeding and good breast drainage helps prevent and manage engorgement.
You see Joanne and Rosie again at 10 days. Joanne's breasts have settled and Rosie is feeding well. However, she has been feeding frequently at night and Joanne's husband, Tom, has suggested bringing the baby to bed with them. Joanne has heard that this increases the risk of SIDS. What would you tell her?
Topic 3.2: Risk of SIDS
It is normal for breastfed infants to feed frequently and wake at night in the first few weeks of life. Some continue to wake for a longer period. Many parents will co-sleep (where the infant is in close physical and/or social relationship with another person) and/or choose to bed-share (adults and infants sharing the same sleep surfaces) during this time. Safe sleeping guidelines should be followed to reduce the risk of SIDS.
Joanne had been on the combined oral contraceptive pill before becoming pregnant. She intends to not use any contraception until she is six months postpartum. Is this a realistic option?
Topic 3.3: Contraception
Lactational Amenorrhoea Method (LAM) of contraception is an effective method of contraception during the first six months postpartum. Non-hormonal forms of contraception are the methods of choice when another form of contraception is needed. Oestrogen containing contraceptive methods should preferably not be used during lactation.
Joanne brings Rosie for immunization at four months. She is concerned about the composition of her milk. Although Rosie had been growing along the 50th percentile, her weight gain has started to slow.
Topic 3.4: Milk composition
The composition of breast milk includes carbohydrates, proteins, fats, vitamins and minerals in unique combinations and concentrations ideally suited to the developing human infant.
Is there any concern about a slowing of growth around this time?
Topic 3.5: Slowing of growth
Infant growth is highest in the first few months postpartum and then begins to slow around four to six months. New WHO growth charts show how breastfed infants 'should' grow and may more accurately reflect normal growth than previously used charts.
Joanne asks about introducing solids at this age. How long is breast milk alone adequate for infant growth?
Topic 3.6: Introducing solids
Breast milk alone is sufficient for growth and development until the infant is around six months of age. Appropriate complementary foods from that time will provide extra energy (especially protein) and micronutrients such as iron and zinc.
What recommendations would you give Joanne about the appropriate time to wean Rosie from the breast?
Topic 3.7: Weaning
There is no set maximum time for breastfeeding to continue although the minimum recommended time for weaning is 12 months (NHMRC, AAP) or two years (WHO). Gradual weaning is ideal.
What recommendations would you give Joanne about the appropriate time to wean Rosie from the breast?

There is no set maximum time for breastfeeding to continue although the minimum recommended time for weaning is 12 months. The WHO recommends breastfeeding for at least two years, with continued breastfeeding for as long as the mother and infant wish1, while the NHMRC recommends continued breastfeeding for at least the first 12 months and then for as long as the mother and infant wish2. Katherine Dettwyler, an anthropologist who has studied the natural weaning age of primates, suggests that without social constraints human children would naturally wean aged between two and a half and seven years3. Breast milk continues to provide immunological benefits to the infant/child until weaning4, and adequate growth is maintained when appropriate complementary foods are given in addition to breastfeeding5.

Gradual weaning, regardless of the age of the infant or child, is ideal. When the child is older, other foods and fluids gradually replace breastfeeds as a source of nourishment so that the child may only be breastfeeding night and morning. These feeds can then be dropped one at a time by providing other foods or distractions at the time. If the child or infant is younger and breastfeeding constitutes all or most of their nourishment, a more structured weaning process is usually required. First, one breastfed is replaced by infant formula. The mother may experience breast engorgement because of this change in feeding routines. A second breastfeed is replaced when the mother feels ready, but it is ideal to wait at least a few days. A similar process continues until the infant is not having any breastfeeds.

Rapid or immediate weaning is not recommended

Rapid or immediate weaning is not recommended unless there is no alternative. It is often physically and psychologically very distressing for both the mother and infant. The mother will also experience painful engorgement and is at increased risk of mastitis. Beyond the immediate postpartum period, lactation suppression medications such as cabergoline have reduced effectiveness.

Case Study Activity

Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.

Notes

  1. # World Health Organization (2003) Global Strategy for Infant and Young Child Feeding
  2. # National Health (2003) Dietary guidelines for children and adolescents in Australia incorporating the infant feeding guidelines for health workers
  3. # Dettwyler KA (2004) When to wean: biological versus cultural perspectives
  4. # Goldman A et al. (1983) Immunologic components in human milk during the second year of lactation
  5. # Buckley KM (2001) Long-term breastfeeding: nourishment or nurturance?