This document has been kindly provided by the Lactation Service of Stamford Hospital.
The highly skilled lactation consultants at Stamford Hospital can provide assistance with your breast feeding issues. Lactation consultants can be reached at 203-276-7829.
A Good Beginning
“Early and often” is still a good rule. Help the mother and newborn to breastfeed within the first hour or so after birth.
Skin to skin has been shown to help both with prolactin production (for milk supply) and breastfeeding behaviors. Dads can help out too, especially while waiting for moms to recover from surgery.
Colostrum is one of the most valuable foods a baby will ever get. Please read the handout The Importance of Colostrum. It is our job to ensure that babies get colostrum.
Although babies can be sleepy and slow to breastfeed in the first 24 hours, and some babies are bothered by excess mucous, optimal is 4 or more times.
If the baby is not beginning to breastfeed after 24 hours, mom can begin pumping. Massage before pumping may help her to secrete enough drops of colostrum to feed it to the baby by syringe or spoon.
Assist baby to latch to breast past the nipple, not necessarily to the edge of the areola.
Help mother to recognize a wide-open mouth (like a yawn) and bring baby to the breast; trying to cram a nipple into a partially open mouth rarely allows for an effective feeding and can cause nipple damage and pain.
Ready-to-feed formula should not be saved from feeding to feeding. Without refrigeration, it should be discarded after 1 hour. It can be refrigerated for up to three hours.
Liquid concentrate can be prepared 24 hours in advance or stored in the covered original container in the refrigerator for 48 hours. Powdered formula can be prepared just before feeding, or 24 hours in advance.
Never microwave formula or breastmilk. It can create hotspots, and will destroy protective factors in the breastmilk.
Alternate the position of the bottlefeeding baby, so that the baby is placed in both arms for feeding
Skin-to-skin contact is important for all babies whether they are breastfed or bottle fed.
Allow baby to pace the feeding. Stop every so often to allow the baby to breathe and burp. Don’t urge baby to finish the bottle if he doesn’t want to.
The Average Experience
n the first 24 hours, the baby may go to breast frequently or not at all. More than four times is preferable. In the second 24 hours, the baby should be at breast at no less than 4-hour intervals. More frequent feeds are preferable, and normal. The baby who goes to breast frequently encourages the milk to come in quickly. When the milk comes in, at about 3-5 days postpartum, babies average 8-12 times in 24 hours. The baby should then have 4 or more yellow stools in a 24-hour period.
In the first day or two, a baby may breastfeed for just 5 minutes at a time, or 20 minutes per side several times during the feeding. After the milk comes in, the average baby will breastfeed for about 15-20 minutes per side, taking both sides at a feeding. The baby should be allowed to finish the first side before switching.
Most babies will take both sides at a feeding, the mother alternating which side to begin the feeding. Some babies prefer or can only manage one side at a time, and often feed a little bit more often than every two to three hours.
A baby who nurses more than once per side at a feeding is “cluster feeding”. This is a normal occurrence. The baby who cluster feeds will not necessarily want to feed again 2-3 hours after the beginning of the feeding. Allowing the baby to sleep a little longer is fine if the baby is cluster feeding.
After the milk comes in, baby should have 4 or more yellow stools per day. A stool may be liquid, seedy, or curdy, and should be enough to measure; more than a spot. Mom should hear the baby swallowing at most feedings, and baby should be content for a while after the feeding. Average weight gain is about 1 ounce per day; many doctors will accept a bit less in the beginning. Many physicians want the baby back at birth weight by the two-week check-up.
Breastfeeding is a supply and demand system. The more frequently the baby goes to breast, the sooner and more copiously the milk comes in. The baby who is nursing often is just doing his job of encouraging a good milk supply. There is no evidence that frequent or prolonged breastfeeding is the cause of sore nipples.
Routine supplementation of a breastfed infant is not necessary, and interferes with a good milk supply and mother and infant bonding. In addition, it interferes with the mother’s confidence that she can feed her baby. Offering a supplement in addition to breastfeeding should ideally be a medical decision
How to supplement should be the parents’ choice . For the parent anxious to exclusively breastfeed, we suggest avoiding bottles as much as possible in the early days. The alternative of syringe feeding is one option.
If the baby is breastfeeding well, the tip of the feeding tube can be slipped into the corner of the baby’s mouth while at the breast. The mother will always need help with this technique; she cannot manage it alone.
Another good alternative is finger feeding. The pad of the finger should be up towards the roof of the baby’s mouth and the supplement should be given very slowly
9:00am – 1:00pm
2:00pm – 4:00pm
Newborn baby’s stomachs are very small and hold only a few cc’s worth of liquid at one time. Small, frequent feedings of colostrum are ideal. Care should be taken not to fill the baby up on large amounts of formula, thus limiting opportunities to feed at the breast. Generally, no more than 15-20 ccs is sufficient. If the baby is nursing moderately well, an ounce or less should be offered, and may not be needed at every feeding. In the first 24 hours especially, supplemental feedings should be small and only used when medically necessary.
If the baby is not going to breast at all, about an ounce or less, taking the baby’s size into consideration, can be offered. The baby needs to be allowed to pace his own feedings.
Again, this depends partially on why the supplement has been ordered, and how much the baby is at the breast. The more the baby feeds at the breast, the less frequently the supplement is needed.
It is important that parents know when they can discontinue the supplement (“when your milk comes in”, “when the baby gains x number of ounces”, etc). It is also helpful for them to know that if the baby is getting a large amount of supplemental feeding, they can taper this off gradually as the breastmilk becomes more plentiful.
Although we often think of a supplement as formula, many mothers can pump or express enough to use colostrums or breastmilk as a supplement, especially after the first few days. Mothers should be offered this option. It is especially important if the baby is getting more supplement than anything else, so that the mother can encourage a good milk supply. In addition, if there is any history of allergy in either of the parents, care must be taken if introducing formula.
Many babies are sleepy, especially in the first 24 hours or just after being circumcised. Any baby that is not breastfeeding well can benefit from the simple technique of skin-to-skin care or kangaroo care. Mother (or father) can cuddle the baby, stripped down to the diaper, against a naked chest between the breasts. A receiving blanket can be folded in quarters and placed over the baby’s back. This technique has been shown to help mothers with prolactin and milk production, and to aid babies’ breastfeeding behaviors.
Some soreness, especially at the beginning of the feed, is common for the first 10-14 days, especially in very fair women. If the pain continues with every suck, the latch should be checked, and other causes considered.
While sore nipples are often caused by improper latch, this is not always the case. Inverted nipples that retract back toward the chest wall can carry moisture which doesn’t dry, causing very sore nipples. Although lanolin and shells may help with this, they sometimes do not.
Tongue-tie, which can prevent the baby from extending her tongue over the gum, or curling around the breast, can also cause sore nipples, and usually must be corrected to control the problem.
Very rarely, no obvious cause can be found for sore nipples. Yeast infections, bacterial infections, and sometimes a history of abuse all can be causes, though less common than those previously mentioned.
We tell new mothers that they can expect their milk to “come in” at about 3 to 5 days postpartum; on the later side if they had a Cesarean birth, earlier if they’ve had a previous child, whether breastfed or not. The breasts will fill with fluid that are aiding in the transition from colostrum to early milk. Just as it is important to breastfeed early and often to help with breastmilk production, it is important to continue the stimulation if breasts begin to become engorged. Continued, unrelieved swelling will send a message to the body to slow down milk production. One reason that we dispense manual pumps is to give new mothers something to use if the nipple itself becomes so hard and tight that milk will not flow or the baby can not latch and suckle. She can use the pump for a few minutes to help soften the nipple to allow baby to latch.
We still suggest a few minutes with a warm towel or in the shower right before a feeding, but using something cold is a time-honored way to reduce swelling. We suggest no more than 20 minutes after a feeding with a cold compress or ice pack. The over-the-counter pain killer suggested by the mom’s physician can also be used (usually acetaminophen or ibuprofen).
Because many new mothers have difficulty seeing colostrum, they believe that there is nothing available for the baby. We know that colostrum is the best food the baby will ever have, in the ideal quantity for frequent, short feedings. It may be helpful to explain that the breasts start making and storing colostrum in about the 16th week of pregnancy. Because the newborn’s stomach is no bigger than her fist, newborns are not designed to take large feedings, and if the baby is allowed free access to the breast, colostrum should be sufficient. If it didn’t work, the human race would have died out a long time ago.
The true cases of flat and inverted nipples can and should be identified during pregnancy. Unfortunately, many are not. While many babies can draw out a flat nipple and breastfeed just fine, many more have difficulty. This is especially true for the baby who has had one or more bottle feedings. Please be patient, assisting the mother with latch-on. This is the time to use a drop or two of formula on the baby’s lips and/or the mother’s nipple, or to express colostrum for the baby to taste and smell. Shells can be worn during the day to help the nipple evert.
Some mothers come from Labor and Delivery with edematous breasts, perhaps due to fluids given during labor. These mothers’ nipples will resolve to their true shape, usually within 24 hours. It is important to assist the mother and baby with optimal position and latch, skin to skin care, and some early pumping if necessary.
In the mother with unresolved flat nipples, alert the Lactation Consultant. Mothers with inverted nipples can be given shells and will be seen by the LC staff.
It is not unusual for a full-term baby to sleep for long periods of time, without feeding, in the first 24 hours. Rather than separate the baby from her mother, use this as a time to facilitate bonding with skin to skin contact. This will aid in prolactin production and breastfeeding behaviors. Continue to assist the mother in latching the baby at regular intervals if the baby wakes, but do not be alarmed if there is no productive breastfeeding behavior at first. Mouthing and licking the nipple, and allowing the nipple to rest in the mouth without much sucking in the very beginning are positive breastfeeding learning behaviors. The baby should wake up at around 24 hours of age. If not, it may be appropriate to give a small amount of formula with a syringe and tube to help get the baby started.
It is more difficult with the near-term, but not really premature, baby under 38 weeks. Often these babies are small and sleepy. They may have more difficulty in getting feeding started, and often have less weight they can afford to lose. It is important to support the mother in her breastfeeding efforts. If supplementation is needed, either to get the baby started, or to add calories, it is best to use the syringe if parents wish, and support some early pumping.
Please note that the syringe is just a short-term solution to what we hope is a temporary problem. It is rarely desirable to send a baby home using only the syringe for feeding, although it may be permissible under certain circumstances.
There are a few especially large babies who have difficulty waiting for the milk to transition. This is especially true if they have been separated from their mothers and bottle- fed. If they get used to the quick flow of a large amount, they may be too impatient to wait for the milk to come in. It is important to encourage the mother to feed frequently, using both breasts twice, before adding a small amount (about1/2 oz.) of formula, preferably at the breast.
Mothers who have been separated from their babies for long periods of time should be offered a pump to stimulate their breasts to initiate and maintain supply. The mother with a baby in the NICU should be offered a pump within the first 12-24 hours. She should be encouraged to pump about every three to four hours around the clock (or at least once during the night) for 10-15 minutes at a time, although 5-7 minutes on day 1 will probably be sufficient. The pump needs to be set up for her, and she needs instruction in how it works. She needs to know that the kit is her property, and she may take it with her when she leaves. Please advise her not to wash the narrow tubing that is part of the kit, and how to clean the rest of it both in the hospital and at home. If the mother has a small or very sick baby in the NICU, and she has indicated a desire to provide milk, it is important that she start pumping by about 12 hours postpartum. If she is not able to hold the flanges to her body, a nurse should assist with this until she is able. If the mother wishes to pump at night, it is important that the nursing staff assist her if needed, including waking her up, if she has asked for that.
Although we are happy to assist mothers with pump rental, please do not promise a particular pump at a particular time. The pumps we use on the floor are assigned to the hospital and cannot go home with a patient, although some believe they are taking the pump in their room home with them. In addition, some of the pumps we have for rental are different than the pumps we have on the floor. We try very hard to get the correct pump for each patient.
It is not our place to tell a mother how to feed her baby, but we do need to educate mothers in optimal breastfeeding practices to reach their goal. Most new mothers do not realize that their continued milk production depends on the baby being at the breast numerous times during the day, and that offering bottles frequently in the early days can prevent a full milk supply from coming in. Additionally, they don’t know that sleeping through the night in the early days can lead to increased, painful engorgement and diminished supply. After the first month or so of frequent feedings, it is appropriate to begin offering a bottle once a day of either expressed milk or formula. We do discuss this in the breastfeeding class on the floor.
Why not? If suckling produces a good milk supply, does it not stand to reason that increased demand increases supply? Pacifiers were meant for the bottle-fed baby who is finished with his feeding and wants to continue to suck. It is almost always appropriate to put the baby to breast.
It is almost impossible to prevent a breastfeeding baby from falling asleep at the breast. Prolactin, which makes mother sleepy and relaxed, is ingested while feeding and has the same effect on baby.