Breastfeeding

Category

Breastfeeding

Dr. Siddartha Gogia is a board-certified pediatric neonatologist specializing in breastfeeding issues. They can help parents and babies with issues like lactation, sore nipples, and breastfeeding positions.

Breast-Feeding Essentials

What is good about breast-feeding?

Babies who are breast-fed have fewer infections and allergies during the first year of life than babies who are fed formula. Breast milk is also inexpensive and served at the perfect temperature. Breast-feeding becomes especially convenient when a mother is traveling with her baby. Overall, breast milk is nature's best food for young babies.

How often should I breast-feed my baby?

The baby should nurse for the first time in the delivery room. The second feeding will usually be 4 to 6 hours later, after he awakens from a deep sleep. Until your milk supply is well established (usually 4 weeks), nurse your baby whenever he cries or seems hungry (demand feeding). Thereafter, babies can receive enough milk by nursing every 2 to 2-and-1/2 hours. If your baby cries and less than 2 hours have passed, he can be rocked or carried in a frontpack. However, if he is hungry, feed him. Waiting more than 2-and-1/2 hours can lead to swollen breasts (engorgement), which decreases milk production. (Feeding less frequently is OK at night, but no more than 5 hours should pass between feedings.)

Your baby will not gain enough weight unless he nurses 8 or more times per day at first. The risks of continuing to nurse at short intervals (more often than every 1 and 1/2 hours) are that "grazing" will become a habit, your baby won't be able to sleep through the night, and you won't have much free time.

How long should each feeding last?

During the first week, bring in your full milk supply by offering both breasts with each feeding. Try 10 minutes on the first breast and as long as your baby wants on the second breast (at least 10 minutes). Alternate which breast you start on. You may need to stimulate your baby to take the second breast.

After your milk supply has come in (by day 8 at the latest), encourage your baby to nurse as long as she wants to on the first breast (up to 20 minutes). This is so your baby can get the high-fat, calorie-rich hind milk. You can tell your baby has finished the first breast when the sucking slows down and your breast becomes soft. Then offer the second breast if your baby is interested. Alternate breasts at the start of each feeding.

How do I know that my baby is getting enough milk?

In the first couple of weeks, if your baby has 3 to 4 good-sized bowel movements per day and 6 or more wet diapers per day, he is getting a good supply of breast milk. (Infrequent bowel movements are not normally seen before a baby is 1 month old.) Also, most babies will act satisfied after completing a feeding.

Your baby should be back to birth weight by 10 to 14 days of age if breast-feeding is going well. Therefore, the 2-week checkup by your baby's health care provider is very important.

The letdown reflex is another sign that you are making enough milk.

What is the letdown reflex?

A letdown reflex develops after 2 to 3 weeks of nursing. It is when you feel tingling in your breast or have milk leak out just before feeding (or when you are thinking about feeding). It also happens to the opposite breast while your baby is nursing.

Letdown is enhanced by getting good sleep, drinking fluids, having a relaxed environment, and reducing stress (such as not expecting much housework to get done). If your letdown reflex is not present yet, take extra naps and ask your family or friends for more help. Also consider calling the local chapter of La Leche League, a support group for nursing mothers.

Do I need to give my baby an extra bottle?

Do not give your baby any routine bottles during the first 4 to 6 weeks after birth because this is when you establish your milk supply. Good breast milk production depends on frequent emptying of your breasts. Extra bottles take away from sucking time on the breast. If your baby is not gaining weight well, see your health care provider or a lactation nurse.

After your baby is 6 weeks old and nursing is well established, you may want to offer your baby a bottle of pumped milk or 1 ounce of formula once a day so that he can get used to a bottle and the artificial nipple. Once your baby accepts bottle feedings, you can occasionally leave your baby with a sitter and go out for the evening or return to work outside the home. You can use pumped breast milk that has been refrigerated or frozen.

Does my baby need extra water?

Babies do not usually need extra water. Even when they have a fever or the weather is hot and dry, breast milk provides enough water.

What should I do if my breasts are swollen or engorged?

If your breasts are badly swollen (engorged), it can decrease your milk production. To prevent engorgement, nurse your baby more often. Also, compress the area around the nipple (the areola) with your fingers at the start of each feeding to soften the areola. For milk release, your baby must be able to grip and suck on the areola as well as the nipple. Every time you miss a feeding (for example, if you return to work outside the home), pump your breasts. Also, whenever your breasts hurt and you are unable to feed your baby, pump your breasts until they are soft. If you don't relieve engorgement, your milk supply can dry up in 2 to 3 days.

How do I pump and use pumped breast milk?

If you want to pump your breasts, you can use a breast pump. Ask your health care provider which breast pump he or she recommends. A breast pump is not always necessary because pumping can be done by hand. Ask you provider about using the Marmet technique to pump by hand.

Pumped breast milk can be stored for 2 to 3 days in a refrigerator and up to 6 months in a freezer. To thaw frozen breast milk, put the container of breast milk in the refrigerator (it will take a few hours to thaw) or place it in a container of warm water until it has warmed up to the temperature your baby prefers.

What should I do if I have sore nipples?

Clean a sore nipple with water after each feeding. Do not use soap or alcohol because they remove natural oils. At the end of each feeding, the nipple can be coated with some breast milk to keep it lubricated. For cracked nipples, apply 100% lanolin after feedings. You can by lanolin without a prescription. Try to keep the nipples dry with loose clothing, air exposure, and nursing pads.

Sore nipples usually are caused by the baby not latching on properly or a feeding position that causes the nipple to be rubbed or pressed incorrectly. When feeding, position your baby so that he directly faces the nipple without turning his neck. At the start of the feeding, hold your breast and squeeze the nipple and areola between your thumb and index finger so that your baby can latch on easily. Throughout the feeding, hold your breast from below so the nipple and areola aren't pulled out of your baby's mouth by the weight of the breast. Slightly rotate your baby's body so that his mouth applies pressure to slightly different parts of the areola and nipple at each feeding.

Start your feedings on the side that is not sore. If one nipple is extremely sore, temporarily limit feedings to 10 minutes on that side. The pain will not improve, however, until your baby starts to correctly latch on and is correctly positioned during feeding.

Does my baby need vitamins or fluoride?

Breast milk contains all the necessary vitamins and minerals except fluoride. Starting at 6 months, children who are breast-feeding and not drinking any water (with fluoride) need 0.25 mg of fluoride each day to prevent tooth decay. Talk to your health care provider to get a prescription for fluoride drops.

 

Do I need to take vitamins?

You can take a multivitamin tablet daily if you are not following a well-balanced diet. You especially need 400 units of vitamin D and 1200 mg of both calcium and phosphorus per day. A quart of milk (or its equivalent in cheese or yogurt) can also meet this requirement.

Should I avoid taking medicine?

Almost any drug a breast-feeding mother takes will be transferred in small amounts to her breast milk. Therefore, try to avoid any medicine that is not essential, just as you did during pregnancy.

Some commonly used medicines that are safe for you to take while nursing are acetaminophen, ibuprofen, penicillins, erythromycin, cephalosporins, stool softeners, antihistamines, decongestants, cough drops, nosedrops, eyedrops, and skin creams. Aspirin and sulfa drugs can be taken if your baby is more than 2 weeks old AND does not have jaundice. Talk to your health care provider about all other drugs. Take drugs that are not harmful immediately after you breast-feed your child so that the level of medicine in the breast milk at the time of the next feeding is low.

Some of the dangerous drugs that can harm your baby are tetracyclines, chloramphenicol, antithyroid drugs, anticancer drugs, or any radioactive substance. Women who must take these drugs should not be breast-feeding or should request a safer form of treatment. Another group of drugs that should be avoided because they can suppress milk production are ergotamines (for migraine), birth control pills with a high estrogen content (most birth control pills are OK), vitamin B6 (pyridoxine) in large doses, and many antidepressants.

Do I need to burp my baby?

Burping is optional. Its only benefit is to decrease spitting up. Air in the stomach does not cause pain. If you burp your baby, burping 2 times during a feeding and for about a minute is plenty. Burp your baby when switching from the first breast to the second and at the end of the feeding.

When can my baby start using a cup?

Introduce your child to a cup at approximately 6 months of age. Total weaning to a cup will probably occur somewhere between 9 and 18 months of age, depending on your baby's individual preference. If you stop breast-feeding before 9 months of age, switch to bottle feeding first. If you stop breast-feeding after 9 months of age, you may be able to go directly to cup feeding.

Call Your Child's Physician within 24 Hours If:

• Your baby doesn't seem to be gaining adequately.
• Your baby has less than six wet diapers per day.
• During the first month, your baby has less than 3 bowel movements per day.
• You suspect your baby has a food allergy.
• You need to take a medication that is not mentioned in this discussion.
• Your breasts do not become full (engorged) before feedings by the time your baby is 5 days old.
• You have painful engorgement or sore nipples that do not respond to the recommended treatment.
• You have a fever (also call your obstetrician).
• You have other questions or concerns.

Breast-Feeding Positions

How should I hold my baby when feeding?

There are 4 main breast-feeding positions: the cradle hold, the cross-cradle hold, the football hold, and lying down.

• Cradle hold The most common position is the cradle hold. This is when you are sitting with your baby in your lap and the baby's head in the crook of your arm. The baby's chest should be against your chest so that she doesn't have to turn her head to reach your nipple. Be sure the arm of the chair is at the right height to support your arm. Use pillows to support your back, your arm, and the baby's head. A footstool is also very helpful to elevate your feet.
• Cross-cradle hold The cross-cradle hold is similar to the cradle hold except your baby is laying the opposite direction, with his head in your hand, rather than the crook of your arm. This is a useful position when first learning to breast-feed because it gives you good control of the baby's head while helping your baby to latch on.
• Football hold Position your baby with his legs under your arm. Hold your baby like a football along your forearm, with the baby's body on your arm and her face toward your breast. Use your other hand to support your breast. The football hold is useful if you have engorged breasts or sore nipples. It is also a good position if you have had a cesarean section and cannot place the baby on your stomach. If you are prone to having plugged ducts, the football hold can help because it helps your baby empty the bottom ducts. It is also a good position for nursing twins!
• Lying down Breast-feeding when you are lying down is useful for night feeding. Lie on your side and place the baby on her side facing you, with her head at your breast. You may want to place a couple of pillows at your back for some extra support. Be sure that the baby can breathe through his nose. This position is restful for you; often both you and the baby will drift off to sleep after feeding. By adjusting your position slightly you can feed the baby from both breasts while lying on one side. (Make sure that you feed from both breasts. If you don't empty both breasts, you can get a plugged milk duct.) After feeding, be sure to place your baby on his back for sleep. Avoid soft sleep surfaces, loose bedding, and situations in which your baby can fall, become entrapped, or be too close to a heating appliance.

How do I get my baby to latch on to my breast?

It is very important to get your baby to latch on correctly to your breast. If the baby is not latched on correctly, you will get sore nipples and the baby won't get as much milk.

To get a good latch:

1. Hold your baby in one of the 4 positions described above. With your other hand, support your breast with your fingers underneath your breast and your thumb on top (C-hold) or rotate your hand into a U-hold with your fingers and thumb on either side of the breast.
2. Get the baby to turn his head toward your breast and open his mouth. This is called the rooting reflex. To do this, bring the baby close to your breast. Then stroke the baby's cheek with your finger. You can also tickle the baby's lower lip with your nipple. When you do this, your baby will naturally want to turn his head and open his mouth.
3. When he opens his mouth, put as much of the areola into the baby's mouth as possible. Make sure the baby has a good grasp of the nipple as well as the areola (brown area around the nipple). NEVER allow the baby to suck on just the nipple. You can guide your breast into a good nursing position so that the nipple and areola don't get pulled out of your baby's mouth by the weight of the breast.
4. Make sure that your baby's nose is not pressed into the breast so that she can't breathe. If your breast is blocking the baby's nose, press a finger against your breast near his nose to allow him to breathe. Also be sure that your baby's body is directly facing the breast.
5. If your baby does not latch on well, remove the baby from your breast by pressing a finger gently on the corner of his mouth. This will break the suction. Then try again.

Tips on Breast-feeding Positions

• As a general rule, anything that works is OK as long as the baby has the whole nipple in her mouth (both nipple and areola) and she can breathe.
• Vary the nursing position to make sure all of the milk ducts are drained of milk.
• Always find a relaxed and comfortable position.

Special Situations

Nursing After Having a Cesarean Section

• The lying-down position may be more comfortable for breast-feeding after you have had a cesarean section. The hospital nurses will help you change from side to side.
• If you nurse using the sitting position, put a pillow on your lap to protect the incision.
• The football hold can also be used, since it keeps the baby from pressing on your incision.

Nursing Premature Infants

• Support the baby's head with the crook of your arm while placing your hand under her bottom. Use your other hand to guide your nipple into her mouth.
• If the baby's nursing reflex is weak, pull down on the baby's chin and direct the nipple into the back of her mouth.

Nursing Twins

• Use the football hold with pillows under each arm to support the babies. Using pillows helps free up your hands.
• You can use a regular sitting position with the babies overlapping.
• You can combine the regular sitting position for one baby and the football hold for the other.
• Alternate between feeding each baby separately and nursing the babies at the same time.
• Don't let one baby feed from just one breast. Alternate breasts to keep a good milk supply in both breasts.
• Nurse the hungriest baby on the fullest breast.

Breast Infection (Mastitis)

What is mastitis?

Mastitis is an infection in the breast. This condition is most common in women who are breast-feeding. You may have both general symptoms of illness and breast symptoms including:

• achy, flulike feeling
• fever
• chills
• headache
• breast pain
• breast redness
• breast firmness
• nipple or areolar pain
• difficulty getting milk to flow.

Call your obstetrician or family physician promptly if you have any symptoms of mastitis. The sooner you start treatment, the sooner you will feel better. Prompt treatment may prevent complications, such as a breast abscess (a pocket of pus requiring drainage).

What is the cause?

Breast infections are usually caused by bacteria. Bacteria are normally present on the nipple and in a baby's mouth. They can enter the breast through a cracked nipple or the milk ducts and cause mastitis.

Many factors can make a breast-feeding mother susceptible to mastitis. One of the principal factors is inadequate drainage of milk from your breasts. Poor emptying can occur by allowing too much time to pass between feedings. Also, milk may not drain well if a duct is clogged, or a tight-fitting bra may obstruct milk flow.

Injury to the breast can make a breast-feeding woman more susceptible to mastitis. The injury may be caused by a baby teething on the breast or incorrectly latching on to the nipple. Use of a breast pump that generates excessive vacuum can also injure the breast.

Exhaustion may contribute to mastitis. For example, returning to work, not getting enough sleep, and having house guests may tire a new mother.

What is the treatment?

• Take all of the antibiotic your doctor prescribes even if you feel much better after a few days. Mastitis is usually treated with an antibiotic for 10 days.
• Rest and stay in bed as much as possible. Get all the help you can for at least the next 2 days.
• Drink plenty of fluids, especially if you have a fever.
• Take medicine for the pain if necessary. You will probably need pain medication during the first 2 days of your illness. Ask your doctor for a prescription if necessary. Ibuprofen is a good choice for over-the-counter pain medication. Only very small amounts of ibuprofen are excreted in breast milk.
• Nurse more often, especially from the side that is infected, to keep your breasts well emptied. You do not have to wean your baby if you have mastitis. In fact, you should nurse more often. You may need to put moist heat on the affected area of your breast before nursing to help start milk flow. For example, put a warm washcloth on the breast, take a warm shower, or submerge the breast in a basin or tub of warm water. You can begin feedings on the side that is not infected and then move your baby to the infected breast once your let-down has been triggered. If you are pumping milk for a sick or premature hospitalized baby when you develop mastitis, discard the milk collected from the infected side until you are well.
• Pump your breasts if necessary. If nursing your baby is too painful or doesn't relieve your breast fullness, you may need to rent an electric breast pump. Often an electric pump will comfortably and efficiently empty your breasts. You may need to rent a breast pump if:
  • The infected breast is still not emptying well even though you have followed the treatment suggestions.
  • Nursing your baby from the infected breast is too painful.
  • Your baby refuses to nurse from the infected breast.

When should I call the doctor?

Call YOUR doctor during office hours if:

• Your symptoms are not better within 48 hours after you start taking antibiotics.
• A tender breast lump develops that is not relieved by nursing.

Call your BABY'S doctor during office hours if:

• You think your milk supply is decreasing.
• Your baby shows any signs of illness such as fever, poor feeding, tiredness, irritability, trouble breathing, or a rash. Call any time if you are worried.
• Your baby develops a diaper rash while you are taking antibiotics. The rash may be due to a yeast infection and may require treatment with a medication.

Breast-Feeding Problems: Plugged Ducts

What is a plugged duct?

A plugged duct is when one or more of the milk ducts become blocked. It will feel like a hard, tender lump in your breast. Plugged ducts are usually caused by incomplete emptying of the breast. A plugged duct can also be caused by stress, fatigue, or a tight bra. Some women are more prone to plugged ducts than others.

Because a plugged duct can lead to a breast infection, it needs to be unplugged as soon as possible.

How can I unplug the duct?

• Nurse on the tender side first when the baby is hungriest and sucks more strongly. This will ensure complete emptying of that breast.
• Massage the breast with the lump, expressing extra milk and trying to unplug the duct.
• Between nursing sessions apply moist heat to the breast. (The best way is to soak in a hot bath while massaging your breast and expressing milk. A hot shower or a heating pad is also helpful.)
• Be persistent! With a plugged duct you have to work with massage, expression, nursing, and moist heat until it clears.
• Sleep on your side instead of your back to assist the flow of milk down the ducts in your breasts.
• Since stress can be an important factor in plugged ducts, make sure you get plenty of rest and relaxation.
• When the plugged duct unclogs, you may feel a burning or pinching.

WARNING: If a plugged duct is accompanied by redness, a painful lump, and/or a fever and flu-like feeling, you could have a breast infection. Call your physician immediately!

How can I prevent plugged ducts?

• Nurse frequently.
• Empty each breast at each nursing.
• Avoid tight or poorly fitting bras.
• Sleep on your side instead of back.
• Get plenty of rest.

General Recommendations for Breast-Feeding Mothers

In general, nursing mothers produce breast milk of excellent quality. However, the amount of milk each woman produces may vary. Your physical well-being, your diet, and how much rest you get can affect your milk supply. But, the most important influences on milk production are how often you feed your baby (or pump your breasts) and how effectively milk is removed from your breasts.

Many women have questions about how they will need to change their lifestyles while nursing. They fear that they may be restricted in many ways. In fact, the vast majority of women can comply with these recommendations for successful breast-feeding:

1. Follow the same guidelines for healthy eating recommended to you during your pregnancy. Eat a variety of foods at regular mealtimes and keep nutritious snacks on hand if you are hungry between meals. Eat more fresh fruits, vegetables, whole-grain breads and cereals, dairy products, and protein-rich meats, fish, poultry, and legumes.
2. Drink plenty of liquids each day. Your body needs extra water to produce breast milk. Pour yourself a glass of water each time you sit down to nurse. If you feel thirsty, make sure you drink more.
3. In general, you can eat any foods. Although breast-fed babies are not allergic to their mother's milk, they can have reactions to substances that appear in the milk from the mother's diet. If your baby is bothered by something you ate, your baby may have a reaction such as excessive crying, stuffy or runny nose, vomiting, diarrhea, cough, or rash on the cheeks or around the bottom. If a particular food or beverage seems to upset your baby, avoid that substance for a week and then try it again to see if it truly affects your baby. The most common foods in a mother's diet that cause allergic symptoms in nursing infants are cow's milk and other dairy products, peanuts, corn, wheat, eggs, fish, soy, citrus fruits, and tomatoes. Often the food producing a reaction in your baby is something you are eating or drinking every day and a food that was a regular part of your diet while you were pregnant. If you think your baby is having a reaction to certain foods you eat, talk to a doctor or dietitian before you eliminate a major food group (such as dairy products or wheat products) from your diet. They can suggest substitute foods that will give you the essential nutrients provided by the foods that bother your baby.
4. Continue taking your daily prenatal vitamins. Remember, however, that vitamin and mineral supplements do not take the place of food. It is better to get your nutrients from a well-balanced diet than to rely on a vitamin and mineral supplement.
5. Don't drink more than 2 cups of coffee, tea, cola, or other caffeine-containing beverages a day. Caffeine passes into your breast milk and can make your baby irritable.
6. It is best to abstain from alcohol while you are breast- feeding, just as you did during your pregnancy. Alcohol is readily passed into human milk. Any heavy drinking or daily drinking of even small quantities of alcoholic beverages could hurt your baby. If you have a hospitalized premature or ill newborn, DO NOT drink ANY alcohol. An occasional beer or glass of wine is probably OK, but you should not have more than 1 or 2 a week.
7. Do not smoke. Smoking can decrease your milk supply. Also, the breakdown products from nicotine can pass to your baby in your milk. If you cannot stop smoking altogether, try to cut down. If you must smoke, do it shortly after nursing your baby. Above all, do not smoke in the same room as your baby or even in the house. Breathing your exhaled smoke can hurt your baby.
8. If you need to take any medicines, including nonprescription drugs, check with your health care provider or pharmacist. You need to make sure that the drug is safe for nursing babies.
9. Never use illegal or street drugs while you are nursing. Drug abuse by nursing mothers can be highly dangerous to breast-fed babies.

Check with your doctor before you start a program to lose weight. Your body uses the fat stored during pregnancy to make breast milk. This is the reason most breast-feeding mothers can expect to lose several pounds each month. However, a strict weight-reduction diet can decrease your milk supply. Attempts to lose weight should be carefully supervised by your doctor while you are breast-feeding.

How Do I Know My Baby Is Getting Enough Milk?

You can't see exactly how much milk your baby takes while nursing. However, you can tell whether breast-feeding is off to a good start if you know what to look for. The following patterns are typical of well-nourished, breast-fed babies during the first month of life.

1. You start producing milk abundantly 2 to 4 days after your baby is born. If your baby seems hungry after most nursings or you do not think your milk has come in by 5 days after delivery, tell your baby's doctor and have your baby weighed.
2. Your baby latches on to your breast correctly and sucks rhythmically for at least 10 to 15 minutes at each feeding. Your baby may pause sometimes while breast-feeding. However, he should nurse vigorously during most of the feeding. You should hear your baby swallow regularly while breast-feeding. Allow your baby to remain at the first breast until it is well drained, so he will receive the rich, high-fat hind milk. When your baby starts to suck less vigorously on the first side or begins to doze off, you can burp him, change his diaper and arouse him to take the second breast. Generally, babies get more milk at a feeding by nursing at both breasts. Since the first breast gets drained better, begin each feeding on a different side. This way, both breasts will get about the same stimulation and emptying.
3. Your newborn nurses at least 8 times every 24 hours. Nurse your baby as often as she shows hunger cues, such as waking from sleep, becoming alert, bringing a hand to her mouth, turning her head, or moving her mouth or tongue. Remember that crying is a late sign of hunger and a baby may not nurse well after crying too long. You can expect your baby to want food about every 1 1/2 to 3 hours, with a single longer stretch (up to 5 hours) between feedings at night. Newborns that feed fewer than 8 times in 24 hours or sleep through the night are not likely to get enough milk. At times you may need to awaken your baby to nurse. Some babies just don't demand to be fed as often as they should, especially in the first few weeks of life.
4. Your baby appears satisfied after nursings and may fall asleep at the second breast. Breast-fed infants who appear hungry after most feedings -- who cry, chew their hands, or often need a pacifier after nursing -- may not be getting enough milk.
5. Your breasts feel full before each feeding and softer after your baby has nursed. One breast may drip milk while your baby nurses on the other side. After the longest time between feedings at night, your breasts should feel particularly full.
6. Your baby's bowel movements look like cottage cheese and mustard by the 4th or 5th day of life. Bowel movements that look like cottage cheese and mustard are called "milk stools." If your baby is still having dark meconium, green, or brown stools by 5 days of age, you should have your baby weighed to see if he is getting enough milk.
7. Your baby urinates 6 or more times a day once your milk has come in. The urine should be colorless, not yellow. If it looks like the diaper has reddish brick dust on it after your baby is older than 3 days, your baby's urine probably is too concentrated and your baby may not be getting enough milk.
8. Your baby has 4 or more good-sized bowel movements each day. Many breast-fed babies have a bowel movement every time they nurse during their first 3 to 4 weeks of life. If your newborn is having fewer than 4 bowel movements each day, you should have your baby weighed to see if he is getting enough milk.
9. Your nipples may be a little tender for the first several days of nursing, especially at the beginning of feedings. The discomfort should be nearly gone by the end of the first week of breast-feeding. Nipple pain that is severe, lasts throughout a feeding, or continues more than 1 week after birth probably means your baby is nursing incorrectly. If your baby doesn't latch on properly to nurse, your infant may not be getting enough milk. If you do have very sore nipples, ask your infant's doctor to check your baby's weight and to refer you to a lactation consultant who can look at how your baby is nursing.
10. Two or three weeks after delivery you may notice the sensations associated with the milk ejection, or milk let-down, reflex. Breast-feeding causes the release of the hormone oxytocin. This hormone causes the uterus to cramp. These "after-pains" with breast-feeding are more noticeable than any early breast sensations. They usually go away 7 to 10 days after the birth of your baby. The sensations of the milk ejection reflex are a tingling, pins-and-needles, or tightening feeling in your breasts as milk begins to flow. When your milk let-down occurs, your baby may start to gulp milk. Milk may drip or spray from the other breast. You may find that just hearing your baby cry causes your milk to let down, even before your baby starts nursing. If you don't notice any signs of milk let-down, your milk supply may be low.
11. Once your milk comes in, your breast-fed baby should gain weight rapidly -- at least 1 ounce each day for the first couple months of life. The only way to be absolutely certain that your baby is getting enough milk is to have your baby weighed regularly. If your baby is not gaining enough weight, your milk supply may be low or your baby may not be nursing effectively. Such breast-feeding difficulties are easier to overcome if you recognize and treat them early. Your baby's doctor can help develop a feeding plan tailored for you and your baby or can refer you to a lactation consultant.

How to Increase Your Milk Supply

How do my breasts produce a generous supply of milk?

Your breasts should produce a generous supply of milk if:

• your baby regularly and effectively sucks from your breasts
• your breasts are regularly and effectively emptied during feedings (or by breast pumping).

Typically, the more milk you remove from your breasts, the more milk you will make. If your milk supply is low, there is a good chance you can increase it by stimulating and emptying your breasts more effectively. In general, the longer your milk supply has been low, the longer it will take to produce more milk. In some cases, it may not be possible to increase a very low milk supply to normal levels no matter what you do.

What causes a low milk supply?

Low milk supply is one of the most common breast-feeding problems for nursing mothers. Frequent causes of a low milk supply include:

• having a non-demanding, sleepy baby who does not awaken often enough to nurse or who does not suck vigorously
• being separated from your baby during the first week after delivery (for example, if your baby was sick and you were not able to nurse or pump)
• having a baby who sucks improperly and doesn't empty your breasts well
• regularly using formula supplement, causing your baby to nurse less frequently
• having a baby who sleeps though the night (7 or more hours) without nursing
• being ill yourself with complications after the delivery, such as high blood pressure, anemia, or an infection
• being under a lot of stress, going on a weight-loss diet, or going back to work
• having very sore nipples that make it hard for you to breast-feed
• having had previous breast surgery, especially if it damaged your milk ducts.

A few women are unable to make sufficient milk even though they are nursing a vigorous, healthy baby and using proper technique. Sometimes no apparent cause can be found for a mother's low milk supply. The popular myth that every woman can breast-feed successfully is simply not true.

How do I increase my milk supply?

• Try to nurse your baby more often. If your baby is sleepy, undress your baby to wake her up. Try switching breasts every 5 minutes. If your baby is underweight, premature, ill, or has neurologic problems, your doctor may recommend that you limit the length of each breast-feeding so you don't tire the baby. As your baby gets stronger, she can nurse for a longer time. Meanwhile, your baby probably will need extra feedings until your milk supply increases and she gains more weight. You can use either infant formula or breast milk that you have pumped for these extra feedings.
• Drink plenty of fluids, eat well, rest, and get support from friends and family. Drink plenty of liquids each day and eat regular nutritious meals, plus healthy snacks. Try to get additional rest by doing only the bare necessities for at least 2 weeks. Try not to get discouraged. Keep thinking positively. Get help and support from your close friends and family.
• Pump your breasts. Use a rented, hospital-grade, electric breast pump--preferably with a double collection system--to pump your breasts after feedings about every 2 to 3 hours. Try to pump right after you nurse your baby. You can go 5 hours without pumping one time at night, but aim for 7 pumpings every 24 hours. Record the amount of milk you pump each time. The totals for each day will help you know how much your milk supply is increasing. Using an electric breast pump to stimulate and empty your breasts is especially important if your baby needs extra feedings of infant formula. Babies getting extra feedings may nurse less often, and some who are fed with a bottle will nurse less effectively. To find where you can rent a pump, call Ameda/Egnell at 1-800-323-4060; Medela, Inc., at 1-800-Tell-You (1-800-835-5968).
• If you think your let-down reflex is inhibited, try the suggestions for conditioning your milk ejection reflex listed on the let-down reflex topic. See The Let-Down Reflex

If you have physical problems, such as severely sore nipples or a breast infection, your milk supply may increase as your nipples heal or your infection is treated.

How do I give my baby extra feedings?

Remember, above all else, your baby's welfare is the most important concern. If your baby is very underweight, the doctor may decide that your infant needs to gain weight fast. In this case the doctor may recommend giving your baby formula or extra breast milk in addition to the breast milk your baby gets from nursing. These extra feedings may be necessary while you work on increasing your milk supply. A seriously underweight infant is not in any condition to stimulate more milk production by long sessions of nursing. Regular use of a hospital-grade electric breast pump after nursings will be more helpful in increasing your milk supply while your baby catches up in his growth. Prompt improvement in your baby's weight will reassure you and your doctor about your baby's health. Your baby will probably nurse better once he reaches a healthy weight.

When extra feedings are necessary, your expressed breast milk or formula can be fed to your baby by bottle, cup, syringe, or a device called a Supplemental Nursing System (SNS). The SNS can give extra milk to your baby while you are breast-feeding. The baby suckles both your breast and a little tube connected to a bottle of formula or expressed breast milk. The SNS can help a baby nurse more effectively by providing a ready flow of milk at the breast. You can get an SNS from Medela, Inc. (1-800-835-5968) or from a lactation consultant. Make sure a health care provider shows you how to use the SNS correctly. Incorrect use of the SNS can keep your baby from getting the right amount of milk.

Bottles are usually the fastest way to feed an underweight baby. Once a baby has reached a healthy weight, one of the other, slower methods can be used. You should not try to use one of these other feeding methods unless a lactation consultant or a health care provider shows you how.\

Introducing a Bottle to a Breast-Fed Baby

Ideally, breast-feeding mothers would be able to nurse their babies at every feeding and never need to give a bottle. Certainly bottles should be avoided until breast-feeding is well established (usually 3 to 4 weeks after your baby's birth). However, once breast-feeding is going well, many mothers want their babies to drink from a bottle occasionally. Women who are going to work outside the home want their babies to become familiar with bottle-feeding so others can feed their babies during the workday. Mothers may choose to have their partners or other people occasionally feed pumped breast milk with a bottle. Rarely, mothers and babies need to be separated as a result of illness.

Some breast-fed babies readily accept a bottle, while others are very resistant to new methods of feeding. Many breast-feeding mothers become frustrated and discouraged when their baby refuses to drink from a bottle. The following suggestions have been found to be helpful in encouraging breast-fed infants to accept a bottle.

1. The most important thing to remember is to stay calm when you offer a bottle to your baby. Your baby probably will resist a bit at first by turning away, grimacing or making a face, or pushing the nipple away with her tongue. Don't force the bottle at any time and stop your efforts right away at the first sign that your baby is becoming unhappy with this lesson.
2. Plan a time when you can devote 10 to 15 uninterrupted minutes to try the bottle. Your baby will feel the pressure if you are rushed.
3. Choose a time when your baby is alert and perhaps slightly hungry so she will be motivated to learn a new way to receive milk. On the other hand, avoid offering a bottle when your baby is very hungry. An upset, frantically hungry baby will be in no mood to try something new.
4. Offer milk that you have pumped from your breasts earlier in the day. Warm the milk first, taking care not to overheat the milk. Because the bottle nipple smells and tastes different from your breast nipple, having a familiar fluid to drink may encourage your baby to try the new feeding method.
5. No particular bottle or nipple works best for every baby. If your baby uses a pacifier, she might prefer a nipple shaped like her pacifier nipple. Stick with one nipple for several days before switching to another. Trying a wide variety of nipples probably will just confuse your baby more.
6. Breast-fed babies often accept a bottle more readily if it is offered by someone other than the mother. If the nursing mother tries to give the bottle, the baby may protest and turn toward the breast to nurse. On the other hand, some breast-fed babies actually accept the bottle better when they are in their own mother's arms and can hear her reassuring voice.
7. Go slowly and gently, first touching the baby's lips with the nipple and watching her reaction. Don't force the nipple past her lips. Instead, let your baby draw the nipple into her mouth at her own pace.
8. Express a little milk from the bottle nipple onto the baby's lips or tongue. Remove the nipple before your baby protests. Keep a smile on your face and keep talking in a reassuring tone the whole time. Babies notice their mothers' and caretakers' facial expressions and take their cues from you.
9. If your baby starts to get upset, try to calm her down by talking in a reassuring tone. As soon as she starts to settle down, remove the nipple. Avoid letting her get very upset and then taking the nipple away. This will teach her that if she protests enough you will remove the nipple. It's better to remove the nipple before she becomes upset or to try to calm her with your voice before you remove the nipple.
10. If your baby is not upset or distressed by the bottle, move the nipple a little further into the baby's mouth and let her explore it with her mouth. Keep smiling and offering encouraging words in a soothing voice. Do not stick the bottle into your baby's mouth with too much force. This may cause the baby to gag.
11. Don't spend more than about 10 minutes trying the bottle. Stop sooner if your baby or you are getting frustrated. It's better to end the session on a positive note and try again tomorrow.

Milk Ejection Reflex

What is the let-down reflex?

When you breast-feed, your baby's sucking stimulates nerves in your nipple. These nerves carry a message to your brain, and a hormone, called oxytocin, is released. Oxytocin flows through your bloodstream to your breasts, where it causes tiny muscle cells around your milk glands to squeeze milk out of the glands and into the milk ducts. This is known as the let-down reflex or the milk ejection reflex.

Once your let-down is working well (usually by 2 weeks after delivery), you may feel a pins-and-needles or tingling sensation in your breasts when you nurse or pump. Milk will usually drip from one breast while you are feeding on the other side. Sometimes your let-down will occur when you hear your baby cry or think about nursing your baby. A well-functioning let-down reflex helps ensure your breasts get emptied and your baby is easily getting milk.

Sometimes a woman's let-down reflex doesn't work as well as it should. This can cause breast-feeding problems. For example, you may have problems emptying milk from your breasts or your baby may not get enough milk.

What causes a poor let-down reflex?

Several situations may prevent the let-down reflex from working well.

• You may have severely sore nipples that cause you to tense up before each nursing.
• You may be stressed, anxious, or tense. For example, you may be trying to pump breast milk during a short break at work.
• You may be separated from your baby. For example, if you have to pump at home while your premature baby is still in the hospital.
• You may have had a previous breast surgery that has damaged the normal nerve pathways to the nipple, such as breast reduction or enlargement surgery. If you have altered sensation in your nipple after surgery (that is, your nipple is either somewhat numb or super-sensitive), it is possible that nerve damage from the procedure could interfere with your let-down reflex.

What can I do to improve my milk flow?

The following suggestions can help trigger the let-down reflex and improve milk flow:

• Try to nurse or pump in a place that is familiar, comfortable, and restful.
• Drink a beverage whenever you sit down to nurse or pump.
• Play soft music or do relaxation exercises before you nurse or pump.
• Gently massage your breasts before you nurse or pump.
• Have your partner give you a backrub before you nurse or pump.
• Put a warm washcloth or heating pad on your breasts, or take a warm shower before you nurse or pump.
• If you are pumping because you are separated from your baby, put a photograph of your baby by the pump.

Are there medical alternatives to improve my milk flow?

A synthetic (man-made) form of oxytocin was formerly marketed as a nasal spray known as Syntocinon. The drug was sometimes prescribed for mothers of premature infants who needed help conditioning their let-down reflex when using a breast pump. Syntocinon is no longer on the market. However, a compounding pharmacist can make the same drug with a prescription from your health care provider.

The Storage and Handling of Breast Milk

There may be times when you need to be away from your baby and unable to nurse. You may need to return to work before your baby has stopped nursing. The baby's father or another person may want to feed the baby. Or, your baby may not be able to breast-feed for a while because of a medical problem. In all these instances when your baby can't be breast-fed, it is best for your baby to be fed milk that has been pumped from your breasts. Thus, you will want to know how to handle and store your breast milk safely for later use.

Preparation and Hygiene

• Always wash your hands thoroughly before you pump your breasts.
• A daily shower or bath will keep your breasts clean.
• After each use of a breast pump, wash all the parts that come into contact with your milk. Use hot soapy water.
• Tell your doctor and your baby's doctor if you become ill or need to take any medication.

Collection of Milk

• Pour the milk expressed during one pumping session into a clean plastic container. (Plastic is better than glass because some of the immune factors in breast milk stick to glass.) You may use a plastic bottle that has been washed in soapy water and rinsed, or a disposable bottle bag. If you use disposable bottle bags, put one inside another to prevent tears or holes.
• Tightly cap bottles. Do not store bottles with nipples attached. Bottle bags are best closed with a clean rubber band.
• Label each container with your baby's name and the date and time the milk was expressed.
• Put several bottle bags in a larger plastic bag to prevent them from sticking to the freezer shelf.

Storage of Breast Milk

Milk may be stored:

• In the refrigerator for at least 72 hours after pumping and 24 hours after thawing (assuming the temperature of the refrigerator is 34°F to 40°F, or 1°C to 4° C)
• In a freezer inside a refrigerator for up to 3 weeks after pumping (assuming the temperature of the freezer is 20°F to 28°F, or -7°C to -2°C)
• In a separate-door freezer for up to 3 months after pumping (assuming the temperature of the freezer is 5°F to 15°F, or -15°C to -9°C)
• In a deep freezer for up to 6 months after pumping (assuming the temperature of the freezer is 0 degrees F or below, or -18 degrees C or below).

Thawing of Milk

Milk may be thawed:

• Slowly in the refrigerator. Volumes of 3 or more ounces (100 or more milliliters) of milk may take several hours to thaw.
• Relatively quickly under running warm water or by placing it in a bowl of warm water. Be sure the top of the container remains above the water at all times. Do not thaw milk at room temperature.

Warming of Milk

You need only to take the chill off cold milk. You do not need to heat it. You may warm chilled milk:

• under warm running water
• in a pan of warm water (not over direct heat)
• in a purchased bottle warmer.

About Microwave Heating

Authorities recommend AGAINST using a microwave oven to either thaw or heat expressed milk. Milk can overheat very easily in a microwave. Babies have been accidentally burned by milk that was too hot. Furthermore, many of the immune properties of breast milk can be destroyed by overheating.

Additional Recommendations

• DO NOT thaw milk by letting it sit out of the refrigerator or freezer at room temperature.
• DO NOT overheat milk. Overheating will cause it to curdle and will destroy some immune components.
• DO NOT leave milk at room temperature for more than 1 hour.
• Milk may be reheated and used for the next feeding if it has not been left at room temperature for more than 1 hour. Throw out any milk left after a second feeding.
• DO NOT refreeze thawed milk.
• DO NOT store milk in the door of your freezer, where the temperature may change frequently.
• Always transport milk on ice in an insulated cooler.

For healthy babies who are not in the hospital, it is safe to layer milk collected at different times on the same day in the same bottle. Chill freshly expressed milk in the refrigerator before adding it to previously frozen milk.