Stress and breastfeeding: How to breastfeed safely in a crisis zone

This article was created in response to the ongoing war in Ukraine for people living in a crisis zone. Any information given below is done so with these circumstances in mind. If you'd like to read this piece in Ukrainian then you can do so for free in the Flo app. 

Breastfeeding is one of the most powerful, natural human tools for survival, and that’s especially true for new parents living in a crisis zone. 

If you’re affected by war, you may have limited access to usual levels of food and water, as well as the clean, safe environment you’re used to. With a baby in tow, this can be understandably scary. But if you’re able to keep breastfeeding, it’s an invaluable resource.

“Breastfeeding is safer if you're in a crisis because you know it’s a clean, fantastic source of nutrition for your baby,” says Dr. Sara Ritchie, assistant professor of pediatrics at Medical University of South Carolina, USA.

“Breastfeeding comes naturally to some, but for a lot of people, it's really hard. So if you’re breastfeeding at all, that’s amazing. And if you’re nursing through a stressful environment, it’s even more of a testament to what the human body can do,” Dr. Ritchie says. Still, you likely have questions and concerns, so Dr. Ritchie is here to help.

Stress and breastfeeding: Can stress impact my milk supply?

Stress can interfere with breastfeeding – but perhaps not in the way you might imagine. “Stress doesn’t really affect the production of the milk,” explains Dr. Ritchie. “In theory, even if you’re super stressed, you can still produce the same amount.”

Instead, stress may slow the release and change the composition of the milk. These factors can trigger a “cycle,” says Dr. Ritchie, where your baby gets upset because they’re not getting the letdown they’re used to and can become fussy and pull off the breast. 

The good news is it’s possible to break that cycle. “If you can find a place to relax or at least a quiet area, that could help you achieve your normal letdown,” she says. This can cause a more positive cycle because breastfeeding releases hormones that lower stress in both you and your baby.

It could also be worth giving some basic de-stressing activities a go — like deep breathing exercises or even meditation — to help break that stress cycle.

Can my own lack of access to food have an impact on milk supply?

According to Dr. Ritchie, there’s often a misconception that malnourishment means you can’t nurse. In fact, she says, moderate malnutrition has a “very small to no effect” on milk production. “The body prioritizes that, which is incredible.”

It’s thought that the milk’s protein content might be a little lower if the breastfeeder is malnourished, but the calorie content is still the same — if not more. This is because the balance of carbohydrates and fats in the milk is thought to increase when the level of protein decreases. Dr. Ritchie adds that access to clean water is really more of a priority than food, in order to keep hydrated to maintain your milk supply. However, the content of fatty acids and vitamins A, C, B6, and B12 in breast milk directly depends on the mother’s diet, so try to maintain good nutrition yourself where possible.

Stress and breastfeeding: I'm struggling to get my baby to latch on, help

Breastfeeding isn’t straightforward for everyone, so Dr. Ritchie encourages trying these tips:

• Get your baby skin to skin.
• Position them with their belly rotated toward you. “Almost think belly to belly — that way, they’re not having to turn their neck to reach the breast.”
• Keep their head aligned and well supported with a hand behind their head. 
• Try to get them to open up as wide as possible and get them to latch at the widest point of their mouth being open. Try not to tilt the breast forward into the baby’s mouth, as this can lead to improper attachment. 

If your baby still isn’t latching, or it’s very painful, consider expressing milk (whether that’s with a pump or hand) and feeding them with a bottle, or even a sterilized cup, spoon, or syringe if you have them on hand.

Can I express without a breast pump?

“Hand expression is a great tool,” says Dr. Ritchie. “Gently massage the breast, starting from the outer part and working inward toward the nipple.”

Remember to be careful about what you’re collecting your milk in. “It needs to be a clean, hopefully sterile container,” says the pediatrician. Ideally, put it in boiling water for 10 minutes. This is especially important if your baby was born prematurely or has a weakened immune system. 

If you’re unable to access boiling water, “regular soapy water” is a good alternative — but only for babies aged 4 months and older, whose guts have matured enough to deal with the lack of sterilization. 

If you don’t have a bottle to use, that’s not a problem when it comes to feeding. “You might just use something like a small medicine cup or shot glass. In an upright position, offer the milk to your baby so that they can lap it almost like a cat,” says Dr. Ritchie. “You can also use a spoon or a syringe, too, if you have access.”

Stress and breastfeeding: I've stopped breastfeeding, can I restart?

The short answer is yes. However, it might not happen for everyone — and it won’t always be immediate. “[It could take] days to weeks. If your baby is under 6 months, it’s going to be a little bit easier because they nurse more frequently. But it’s possible to relactate up until 12 months and maybe even after that,” the pediatrician explains. 

So … how? “Start with the basic things, so skin to skin, because that triggers the hormone oxytocin to create a letdown. Then encourage frequent suckling, at least every 2 hours, allowing your baby to latch even if there’s nothing flowing. The more you do this, the more triggers you’re going to send to your brain to make milk.”

Any ideas for making a makeshift nipple shield?

It’s tricky to recreate one with limited resources, says Dr. Ritchie. Instead, she advises expressing a bit so that your breasts aren’t so full. 

“When they’re really full, it’ll flatten the nipple. A nipple shield is just creating a longer nipple for your baby to latch on to. So if you can express to empty the breasts a little, you have slightly softer tissue, so you can use your fingers to work the nipple into a more peaked form for an easier latch,” she suggests.

Stress and breastfeeding: How do I keep track of feeds?

The key during a crisis is to keep it as simple as possible. “Use tick marks to physically jot down how many times in a 24-hour period you’ve nursed,” suggests Dr. Ritchie. 

A newborn to 2-month-old will need somewhere between 10 to 12 feeds throughout the course of a 24-hour period. But if your baby is closer to 6 months or older, it’ll be nearer 6 times in a day. 

“If you have access to a clock, aim for about every 3 hours, especially for younger infants,” she suggests.

Stress and breastfeeding: Are there any reassuring signs that my baby is doing okay nutritionally?

During a time of stress, some reminders that your baby is doing well could really help your mental health. 

Luckily, there are a few physical signs that suggest your baby is well hydrated, says Dr. Ritchie. These include:

• Your baby has wet diapers regularly (“about 5 to 6 or more in a day”).
• The soft spot on the top of the head (the fontanelle) is nice and flat.
• Your baby is making tears when they cry. (Babies start crying from 2 weeks old, so only use this as a marker of hydration if they’re older than that.)
• The inside of their mouth “is wet with drool.”

If you have access to a scale, that’s also a really good measure. In the first month of life, your baby should be putting on about 30 grams a day. Beyond that, Dr. Ritchie says healthy weight gain per week is:

• 0 to 4 months - 155 to 240 grams
• 4 to 6 months - 85 to 130 grams
• 6 to 12 months - 40 to 85 grams

If you’re concerned your milk supply isn’t providing enough nutrition, Dr. Ritchie suggests encouraging your baby to latch more often to encourage more production. 

If that’s not working, you might need to supplement breast milk. If you have access to ready-to-feed formula or you have a safe way to mix formula with clean water, try that first.

If your baby is 6 months or older, Dr. Ritchie suggests some alternative options to help get you through “in a pinch”:

• A pasteurized or boiled full cream animal milk (goat, cow, buffalo, sheep, or camel)
• Reconstituted, evaporated milk (not condensed milk)
• Any kind of fermented milk or yogurt product
• Ultra-high temperature milk
• Plain water (bottled/boiled and cooled) but only if given in addition to breast milk or formula to babies aged 6 months or older. If plain water is given as the sole sustenance, it lacks necessary electrolytes and could do more harm than good.

In slightly more desperate situations, Dr. Ritchie advises that you could feed your baby oral rehydration solutions [often used by people doing endurance sports] in the very short term. These may be available from aid organizations working in a crisis zone. However, she notes: “With a younger baby, you wouldn’t want to go more than 24 hours using that. With a baby aged 6 months plus, you might be able to use it for 48 hours or so.”

My milk supply has dropped, and my baby isn’t getting enough nutrition. Is it safe for someone else to breastfeed them?

Getting someone else to breastfeed your baby is actually an age-old phenomenon, with “wet nurses” having been relied upon in society. So, yes, but there are some considerations you’d need to take into account.

“There are some organizations that try to get donor milk to crisis zones. Ideally, getting pasteurized donor milk via one of these would be your first preference,” says Dr. Ritchie.

If that’s not possible, and you’ve got someone at hand who might be able to help breastfeed your baby, ideally, you’re looking for someone who has a baby that’s similar in age. It’s not a total deal-breaker, but the composition of your milk changes as the baby gets older, explains Dr. Ritchie, so the closer in age, the better.

Beyond that, avoid using someone who:

• Is HIV positive
• Has known hepatitis
• Has known tuberculosis
• Is on any medications or extra supplements (especially chemotherapy or similar)
• Is a big smoker
• Has a high alcohol intake

Stress and breastfeeding: How early can I start giving my baby solids?

“At 4 months, we tend to say that the gut is ready for solid food,” says Dr. Ritchie. “This is the minimum age that it would be safe to go ahead and try some soft foods.”

Foods to avoid include:

• Hard nuts
• Popcorn
• Honey (for babies under 12 months)
• Unpasteurized foods
• Foods with added sugar (biscuits, muffins, flavored yogurts)

If you’re relying on canned or tinned foods, Dr. Ritchie advises paying attention to the salt content and avoiding continuous use if it contains high salt levels.

How long can I exclusively breastfeed my baby if access to other food is sparse?

If your child is approaching toddlerhood, but you’re unable to guarantee a supply of food, it’s natural to consider breastfeeding full-time for longer. So, is it advisable?

According to Dr. Ritchie, “It’s safe to exclusively breastfeed if you don’t have access to any sort of complementary foods for a year — and probably even longer after that.” After 6 months, they ideally need additional iron and vitamin D from food, a supplement, or natural sunlight (vitamin D only) if it’s possible to access any of these. “But if you can’t, that’s okay.” Your child will be more resilient than you think.