Breastfeeding is the natural, physiologic way of feeding infants and young children, and human milk is the milk made specifically for human infants. Formulas made from cow’s milk or soybeans (even “designer formulas”) are only superficially similar to human milk, and advertising which states otherwise is misleading. Breastfeeding should be easy and trouble free for most mothers. A good start helps to ensure breastfeeding is a happy experience for both mother and baby.
The vast majority of mothers are perfectly capable of breastfeeding their babies exclusively for about six months. In fact, most mothers produce more than enough milk. Unfortunately, outdated hospital routines based on bottle feeding still predominate in too many health care institutions and make breastfeeding difficult, even impossible, for too many mothers and babies. For breastfeeding to be well and properly established, a good start in the early few days can be crucial. Admittedly, even with a terrible start, many mothers and babies manage.
The trick to breastfeeding is getting the baby to latch on well. A baby who latches on well, gets milk well. A baby who latches on poorly has more difficulty getting milk, especially if the supply is low. A poor latch is similar to giving a baby a bottle with a nipple hole that is too small—the bottle is full of milk, but the baby will not get much. When a baby is latching on poorly, he may also cause the mother nipple pain. And if he does not get milk well, he will usually stay on the breast for long periods, thus aggravating the pain. Unfortunately anyone can say that the baby is latched on well, even if he isn’t. Too many people who should know better just don’t know what a good latch is. Here are a few ways breastfeeding can be made easy:
- A proper latch is crucial to success. This is the key to successful breastfeeding. Unfortunately, too many mothers are being “helped” by people who don’t know what a proper latch is. If you are being told your two day old’s latch is good despite your having very sore nipples, be sceptical, and ask for help from someone else who knows. Before you leave the hospital, you should be shown that your baby is latched on properly, and that he is actually getting milk from the breast, and that you know how to know he is getting milk from the breast (open mouth wide—pause—close mouth type of suck). See also the website http://www.breastfeedinginc.ca/content.php?pagename=videos for videos on how to latch a baby on (as well as other videos). If you and the baby are leaving hospital not knowing how to identify a good latch, get experienced help quickly (see handout When Latching). Some staff in the hospital will tell mothers that if the breastfeeding is painful, the latch is not good (usually true), so that the mother should take the baby off and latch him on again. This is not a good idea. The pain usually settles, and the latch should be fixed on the other side or at the next feeding. Taking the baby off the breast and latching him on again and again only multiplies the pain and the
- The baby should be at the breast immediately after birth. The vast majority of newborns can be at the breast within minutes of birth. Indeed, research has shown that, given the chance, many babies only minutes old will crawl up to the breast from the mother’s abdomen, latch on and start breastfeeding all by themselves. This process may take up to an hour or longer, but the mother and baby should be given this time together to start learning about each other. Babies who “self- attach” run into far fewer breastfeeding problems. This process does not take any effort on the mother’s part, and the excuse that it cannot be done because the mother is tired after labour is nonsense, pure and simple. Incidentally, studies have also shown that skin-to-skin contact between mothers and babies keeps the baby as warm as an incubator (see section on skin to skin contact). Incidentally, many babies do not latch on and breastfeeding during this time. Generally, this is not a problem, and there is no harm in waiting for the baby to start breastfeeding. The skin to skin contact is good for the baby and the mother even if the baby does not latch
- The mother and baby should room in together. There is absolutely no medical reason for healthy mothers and babies to be separated from each other, even for short periods. *In Victoria, you and your baby will room in together unless there are significant complications for either you or the
- Health facilities that have routine separations of mothers and babies after birth are years behind the times, and the reasons for the separation often have to do with letting parents know who is in control (the hospital) and who is not (the parents). Often, bogus reasons are given for separations. One example is that the baby passed meconium before birth. A baby who passes meconium and is fine a few minutes after birth will be fine and does not need to be in an incubator for several hours’ “observation”.
- There is no evidence that mothers who are separated from their babies are better rested. On the contrary, they are more rested and less stressed when they are with their babies. Mothers and babies learn how to sleep in the same rhythm. Thus, when the baby starts waking for a feed, the mother is also starting to wake up naturally. This is not as tiring for the mother as being awakened from deep sleep, as she often is if the baby is elsewhere when he wakes If the mother is shown how to feed the baby while both are lying down side by side, the mother is better rested.
- The baby shows long before he starts crying that he is ready to feed. His breathing may change, for example. Or he may start to stretch. The mother, being in light sleep, will awaken, her milk will start to flow and the calm baby will be content to nurse. A baby who has been crying for some time before being tried on the breast may refuse to take the breast even if he is ravenous. Mothers and babies should be encouraged to sleep close to one another in hospital. This is a great way for mothers to rest while the baby nurses. Breastfeeding should be relaxing, not
- Artificial nipples should not be given to the baby. There seems to be some controversy about whether “nipple confusion” exists. Babies will take whatever gives them a rapid flow of fluid and may refuse whatever does not. Thus, in the first few days, when the mother is normally producing only a little milk (as nature intended), and the baby gets a bottle (as nature intended?) from which he gets rapid flow, the baby will tend to prefer the rapid flow method. You don’t have to be a rocket scientist to figure that one out, though many health professionals, who are supposed to be helping you, don’t seem to be able to manage it. Note, it is not the baby who is confused. Nipple confusion includes a range of problems, including the baby not taking the breast as well as he could and thus not getting milk well and/or the mother getting sore nipples. Just because a baby will “take both” does not mean that the bottle is not having a negative effect. Since there are now alternatives available if the baby needs to be supplemented (see handout #5, Using a Lactation Aid, and handout #8 Finger Feeding) why use an artificial nipple?
- No restriction on length or frequency of breastfeedings. A baby who drinks well will not be on the breast for hours at a time. Thus, if he is, it is usually because he is not latching on well and not getting the milk that is available. Get help to fix the baby’s latch, and use compression to get the baby more milk (handout #15, Breast Compression). Compression works very well in the first few days to get the colostrum flowing well. This, not a pacifier, not a bottle, not taking the baby to the nursery, will
- Supplements of water, sugar water, or formula are rarely Most supplements could be avoided by getting the baby to take the breast properly and thus get the milk that is available. If you are being told you need to supplement without someone having observed you breastfeeding, ask for someone to help who knows what they are doing. There are rare indications for supplementation, but often supplements are suggested for the convenience of the hospital staff. If supplements are required, they should be given by lactation aid at the breast (see handout #5), not cup, finger feeding, syringe or bottle. The best supplement is your own colostrum. It can be mixed with 5% sugar water if you are not able to express much at first. Formula is hardly ever necessary in the first few days.
- Free formula samples and formula company literature are not gifts. There is only one purpose for these “gifts” and that is to get you to use formula. It is very effective, and it is unethical marketing. If you get any from any health professional, you should be wondering about his/her knowledge of breastfeeding and his/her commitment to breastfeeding. “But I need formula because the baby is not getting enough!” Maybe, but, more likely, you weren’t given good help and the baby is simply not getting the milk that is available. Even if you need formula, nobody should be suggesting a particular brand and giving you free samples. Get good Formula samples are not help.
Under some circumstances, it may be impossible to start breastfeeding early. However, most “medical reasons” (maternal medication, for example) are not true reasons for stopping or delaying breastfeeding, and you are getting misinformation. Get good help. Premature babies can start breastfeeding much, much earlier than they do in many health facilities. In fact, studies are now quite definite that it is less stressful for a premature baby to breastfeed than to bottle feed. Unfortunately, too many health professionals dealing with premature babies do not seem to be aware of this.
Questions? Visit http://www.breastfeedinginc.ca/contact.php or the book Dr. Jack Newman’s Guide to Breastfeeding ( called The Ultimate Breastfeeding Book of Answers in the USA)
Handout #1. Breastfeeding—Starting Out Right. Revised January 2005 Written by Jack Newman, MD, FRCPC. © 2005
Push baby’s bottom into your body with the side (the same side as where your baby finger is) of your forearm.
- This will bring him towards your breast with the nipple pointing to the roof of his mouth
- Mother’s hand under the baby’s face, palm
- Head supported but NOT pushed in against
- Head tilted back
- Baby’s body and legs wrapped in around
- Use your whole arm to bring the baby onto the breast, when mouth wide.
- Chin and lower jaw touch breast
WATCH LOWER LIP, aim it as far from base of nipple as possible, so tongue draws lots of breast into mouth. Move baby’s body and head together – keep baby uncurled.
Once latched, top lip will be close to nipple, areola shows above lip. Keep chin close against breast.
WIDE MOUTH / GAPE
Need mouth wide before baby moved onto breast. Teach baby to open wide/gape :
- Move baby toward breast, touch top lip against nipple
- Move mouth away SLIGHTLY
- Touch top lip against nipple again, move away again
- Repeat until baby opens wide and has tongue forward
- Or, better yet, run nipple along the baby’s upper lip, from one corner to the other, lightly, until baby opens wide
- Move baby not breast
MOTHER’S VIEW WHILE LATCHING BABY
MOTHER’S VIEW OF NURSING BABY
RECOMMENDATIONS FOR THE MOTHER
- Sit with straight, well-supported back
- Keep your trunk facing forwards, lap flat
Baby’s position before feed begins
- On pillow can be helpful,
- Nipple points to the baby’s upper lip or nostril
- Placed not quite tummy to tummy, but so that baby comes up to breast from below and baby’s eyes make contact with mother’s
Support your breast
- Firm the inner breast tissue by raising breast slightly with fingers placed flat on chest wall and thumb pointing up (if helpful, also use sling or tensor bandage around breast)
Move baby quickly on to breast
- Keep Baby’s head tilted back slightly, pushing in across shoulders so chin and lower jaw make first contact (not nose) while mouth still wide open, keep baby uncurled (means tongue nearer breast) lower lip is aimed as far from nipple as possible so baby’s tongue draws in maximum amount of breast tissue
Mother needs to AVOID
- Pushing her breast across her body
- Chasing the baby with her breast
- Flapping the breast up and down
- Holding breast with scissor grip
- Not supporting breast
- Twisting her body towards the baby instead of slightly away
- Aiming nipple to centre of baby’s mouth (instead, aim at the roof of baby’s mouth)
- Pulling baby’s chin down to open mouth
- Flexing baby’s head when bringing to breast
- Moving breast into baby’s mouth instead of bringing baby to breast
- Moving baby onto breast without a proper gape
- Not moving baby onto breast quickly enough at height of gape
- Having baby’s nose touch breast first and not the chin
- Holding breast away from baby’s nose (not necessary if the baby is well latched on, as the nose will be away from the breast anyway)
See videos at http://www.breastfeedinginc.ca
Handout A, When Latching Revised : January 2005
Original written and designed by Anne Barnes
Breastfeeding mothers frequently ask how to know their babies are getting enough milk. The breast is not the bottle, and it is not possible to hold the breast up to the light to see how many ounces or millilitres of milk the baby drank. Our number- obsessed society makes it difficult for some mothers to accept not seeing exactly how much milk the baby receives. However, there are ways of knowing that the baby is getting enough. In the long run, weight gain is the best indication whether the baby is getting enough, but rules about weight gain appropriate for bottle fed babies may not be appropriate for breastfed babies.
Ways of knowing
- Baby’s nursing is characteristic. A baby who is obtaining good amounts of milk at the breast sucks in a very characteristic way. When a baby is getting milk (he is not getting milk just because he has the breast in his mouth and is making sucking movements), you will see a pause at the point of his chin after he opens to the maximum and before he closes his mouth, so that one suck is (open mouth wide–> pause–>close mouth). If you wish to demonstrate this to yourself, put your index or other finger in your mouth and suck as if you were sucking on a straw. As you draw in, your chin drops and stays down as long as you are drawing in. When you stop drawing in, your chin comes back up. This same pause that is visible at the baby’s chin represents a mouthful of milk when the baby does it at the breast. The longer the pause, the more the baby got. Once you know about the pause you can cut through so much of the nonsense breastfeeding mothers are being told—like feed the baby twenty minutes on each side. A baby who does this type of sucking (with the pauses) for twenty minutes straight might not even take the second side. A baby who nibbles (doesn’t drink) for 20 hours will come off the breast hungry. The website http://www.breastfeedinginc.ca has videos that show this pause in the baby’s
- Baby’s bowel movements. For the first few days after delivery, the baby passes meconium, a dark green, almost black, substance. Meconium accumulates in the baby’s gut during pregnancy. It is passed during the first few days, and by the third day, the bowel movements start becoming lighter, as more breastmilk is taken. Usually by the fifth day, the bowel movements have taken on the appearance of the normal breastmilk stool. The normal breastmilk stool is pasty to watery, mustard coloured, and usually has little odour. However, bowel movements may vary considerably from this description. They may be green or orange, may contain curds or mucus, or may resemble shaving cream in consistency (from air bubbles). The variations in colour do not mean something is wrong. A baby who is breastfeeding only, and is starting to have bowel movements that are becoming lighter by day 3 of life, is doing
Without becoming obsessive about it, monitoring the frequency and quantity of bowel motions is one of the best ways, next to observing the baby’s drinking, (see above, and videos at http://www.breastfeedinginc.ca) of knowing if the baby is getting enough milk. After the first three to four days, the baby should have increasing bowel movements so that by the end of the first week he should be passing at least two to three substantial yellow stools each day. In addition, many infants have a stained diaper with almost each feeding. A baby who is still passing meconium on the fourth or fifth day of life, should be seen at the clinic the same day. A baby who is passing only brown bowel movements is probably not getting enough, but this is not very reliable.
Some breastfed babies, after the first three to four weeks of life, may suddenly change their stool pattern from many each day, to one every three days or even less. Some babies have gone as long as 15 days or more without a bowel movement. As long as the baby is otherwise well, and the stool is the usual pasty or soft, yellow movement, this is not constipation and is of no concern. No treatment is necessary or desirable, because no treatment is necessary or desirable for something that is normal.
Any baby between five and 21 days of age who does not pass at least one substantial bowel movement within a 24 hour period should be seen at the breastfeeding clinic the same day. Generally, small, infrequent bowel movements during this time period mean insufficient intake. There are definitely some exceptions and everything may be fine, but it is better to check.
- With six soaking wet (not just wet) diapers in a 24 hours hour period, after about 4-5 days of life, you can be reasonably sure that the baby is getting a lot of milk (if he is breastfeeding only). Unfortunately, the new super dry “disposable” diapers often do indeed feel dry even when full of urine, but when soaked with urine they are heavy. It should be obvious that this indication of milk intake does not apply if you are giving the baby extra water (which, in any case, is unnecessary for breastfed babies, and if given by bottle, may interfere with breastfeeding). The baby’s urine should be almost colourless after the first few days, though occasional darker urine is not of concern.
During the first two to three days of life, some babies pass pink or red urine. This is not a reason to panic and does not mean the baby is dehydrated. No one knows what it means, or even if it is abnormal. It is undoubtedly associated with the lesser intake of the breastfed baby compared with the bottle fed baby during this time, but the bottle feeding baby is not the
standard on which to judge breastfeeding. However, the appearance of this colour urine should result in attention to getting the baby well latched on and making sure the baby is drinking at the breast. During the first few days of life, only if the baby is well latched on can he get his mother’s milk. Giving water by bottle or cup or finger feeding at this point does not fix the problem. It only gets the baby out of hospital with urine that is not red. Fixing the latch and using compression will usually fix the problem (See Handout B: Protocol to Increase Breastmilk Intake by the Baby). If relatching and breast compression do not result in better intake, there are ways of giving extra fluid without giving a bottle directly (handout #5 Using a Lactation Aid). Limiting the duration or frequency of feedings can also contribute to decreased intake of milk.
The following are NOT good ways of judging
Your breasts do not feel full. After the first few days or weeks, it is usual for most mothers not to feel full. Your body adjusts to your baby’s requirements. This change may occur quite suddenly. Some mothers breastfeeding perfectly well never feel engorged or full.
- The baby sleeps through the night. Not necessarily. A baby who is sleeping through the night at 10 days of age, for example, may, in fact, not be getting enough milk. A baby who is too sleepy and has to be awakened for feeds or who is “too good” may not be getting enough milk. There are many exceptions, but get help
- The baby cries after feeding. Although the baby may cry after feeding because of hunger, there are also many other reasons for crying. See also handout #2 Colic in the Breastfeeding Baby. Do not limit feeding times. “Finish” the first side before offering the
- The baby feeds often and/or for a long time. For one mother feeding every three hours or so may be often; for another, three hours or so may be a long period between feeds. For one, a feeding that lasts for 30 minutes is a long feeding; for another, it is a short one. There are no rules how often or for how long a baby should nurse. It is not true that the baby gets 90% of the feed in the first 10 minutes. Let the baby determine his own feeding schedule and things usually come right, if the baby is suckling and drinking at the breast and having at least two to three substantial yellow bowel movements each day. Remember, a baby may be on the breast for two hours, but if he is actually feeding or drinking (open wide—pause—close mouth type of sucking) for only two minutes, he will come off the breast hungry. If the baby falls asleep quickly at the breast, you can compress the breast to continue the flow of milk (handout #15, Breast Compression). Contact the breastfeeding clinic with any concerns, but wait to start supplementing. If supplementation is truly necessary, there are ways of supplementing which do not use an artificial nipple (handout #5, Using a Lactation Aid).
- “I can express only half an ounce of milk”. This means nothing and should not influence you. Therefore, you should not pump your breasts “just to know”. Most mothers have plenty of milk. The problem usually is that the baby is not getting the milk that is available, either because he is latched on poorly, or the suckle is ineffective or both. These problems can often be fixed
- The baby will take a bottle after feeding. This does not necessarily mean that the baby is still hungry. This is not a good test, as bottles may interfere with
- The five week old is suddenly pulling away from the breast but still seems hungry. This does not mean your milk has “dried up” or decreased. During the first few weeks of life, babies often fall asleep at the breast when the flow of milk slows down even if they have not had their fill. When they are older (four to six weeks of age), they no longer are content to fall asleep, but rather start to pull away or get upset. The milk supply has not changed; the baby has. Compress the breast (handout #15, Breast Compression) to increase
Notes on scales and weights
- Scales are all different. We have documented significant differences from one scale to another. Weights have often been written down wrong. A soaked cloth diaper may weigh 250 grams (half a pound) or more, so babies should be weighed naked or with a brand new dry
- Many rules about weight gain are taken from observations of growth of formula feeding babies. They do not necessarily apply to breastfeeding babies. A slow start may be compensated for later, by fixing the breastfeeding. Growth charts are guidelines
Questions? http://www.breastfeedinginc.ca or my book Dr. Jack Newman’s Guide to Breastfeeding ( called The Ultimate Breastfeeding Book of Answers in the USA)
Handout #4. Is My Baby Getting Enough?Revised January 2005 Written by Jack Newman, MD, FRCPC. © 2005
Many women are under the impression that it is necessary to own or use a pump to breastfeed. This is not so. There are very few circumstances under which it is necessary to express your milk. But women are being encouraged to pump their milk and give it to baby via bottle for the most unnecessary reasons: Weddings, doctor’s appointments, shopping…why not take the baby with you? How can babies not be welcome at weddings? Or, “so the father can feed the baby”! Partners were not meant to feed babies milk, and giving a bottle is not really helping. But they certainly can help feed the baby by helping mother with compressions, for example, (see Handout: #15 Breast Compressions) and they can help mothers in so many other ways as well. The pump should not replace the baby; you and your baby receive numerous benefits in addition to nutrition by breastfeeding. No pump is as efficient as the natural pump that was made for your body, your baby! A baby who breastfeeds well is the best pump, but, granted some babies don’t breastfeed well. You do not need a breast pump to breastfeed; uninformed use of a breast pump can lead to premature weaning.
- There is more to breastfeeding than just the
- Obviously, if you can pump a lot, you are producing a lot, but if you cannot pump a lot, this does not mean your milk production is low. Do not pump to “find out how much you are producing”.
- The most effective artificial pumps are high-powered, double, electric, and hospital-grade with adjustable pressure and speed. There are many pumps on the market that are just not very
- Improper use of a breast pump can lead to problems. Read all instructions
- It is important that milk be expressed and/or pumped after the feed as the breasts should be as full as possible for the baby’s feeding. Babies respond to fast flow (see Handout #15, Breast Compression), and pumping before the feed will reduce the amount of milk in the
Pump immediately after the feed–waiting an hour or so decreases the likelihood the breast will be full as possible for the next feed.
- Place nipple in the center of the flange (unlike nipple placement in baby’s mouth, which should always be off-centre and pointed toward the roof of baby’s mouth (see Handout: A: When Latching).
- Put the pump on the lowest setting that extracts milk, not the highest setting you can
- Pump for 15 minutes each side. If breasts run “dry” before 15 minutes is up, pump until dry then add 2
- Remember, pumping should not hurt. If it hurts:
- Lower the suction setting
- Ensure the nipple is centered in the flange
- Pump for a shorter period of time
Cleaning the pump
All pumping equipment should be sterilized before first usage, thereafter it only requires washing with hot, soapy, water or by dishwasher.
- After each pumping: either place the pumping kit (not the tubes or motor) in the refrigerator until the next pumping, or if not pumping the same day, hot-water wash and hot-water rinse well, then air
- Remember to take apart all pieces of the pump for cleaning—including the smallest pieces, and to ensure that no milk has clumped in the flange
Many women find that hand expression is an efficient way to pump when only occasional expression is required. In fact, when the milk production is not abundant (as in the first few days), it is often easier to get milk with hand expression than with a pump and many women fined this the easiest way to express mature milk as well.
- Place thumb and index finger on either side of the nipple, about 3 to 5 cm (1-2 inches) back from the
- Press gently inward toward the rib
- Roll fingers together in a slight downward
- Repeat all around the nipple if
Unlike formula, breast milk is anti-infective, antibacterial, antifungal, and antiviral.
- Breastmilk will stay good:
- At room temperature for at least 8-12
- In the fridge for at least 8-11
- In the freezer, at the back, for many
Get used to the taste and smell of breast milk so you’ll always know if it is good.
- Due to the high fat content of breastmilk, storage of any kind will produce a separation in the liquid. This is normal; a gentle mixing will give it a homogeneous look once
- Breastmilk may taste different after freezing; this is normal
- Never heat breastmilk in the
- Babies will often take cold milk, but if heating is desired, or if milk needs to be defrosted, place container or bag of milk in a cup of warm water for a minute or
Encouraging the M.E.R. (milk ejection reflex) or “let down”
If your baby is not present, you can encourage the “let down” reflex artificially, by having a picture of your baby to look at, or by having a piece of his clothing next to you.
- Apply a warm wet cloth to your
- Massage the breasts in small circular motions around the perimeter of the
- Gently stroke your breasts with your fingernails in a downward motion toward the nipple
- Lean forward and gently shake the
- Gently roll the nipple between your finger and
You may feel the milk ejection reflex or notice your breasts leaking or you may not. You are likely to pump more milk faster if you pump both breasts at the same time. You do not need to feel or be aware of the milk ejection reflex in order to make milk. Some women may feel thirsty, sweaty, sleepy, or dizzy during a let down. However, many women do not feel this milk ejection response ever in their whole breastfeeding experience. Some women only become aware of it after the first few weeks. This has absolutely no bearing on milk supply. Breast compressions, while pumping, can be very effective at increasing the amount expressed, it may be a bit awkward at first, but it can be done (mothers have fixed the cups so that they sit inside the bra and then use compressions) or the partner can do it.
Questions? http://www.breastfeedinginc.ca or Jack’s book, Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA), or our Video/ DVD: Dr. Jack Newman’s Visual Guide to Breastfeeding.
Handout # 27. Expressing Milk. January 2005
Written by Edith Kernerman, IBCLC, RLC and Jack Newman, MD, FRCPC. © 2005