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Breast Feeding Basics

Many mothers think that a baby who eats frequently is not getting enough. But this is not true. Babies need small frequent feedings in the first few weeks.

Breast fed infants may eat more frequently than formula fed infants especially in the first few weeks of life. Remember the stomach of a newborn is small, the size of a walnut, and is not made to hold large volumes of milk. Breastfed infants do eat more frequently than formula fed infants due to the difference in the milk fat content.

More frequent feedings or cluster feedings are common in the evenings. As baby get older the baby may feed more frequently for a few days and then return to the previous regular feeding frequency. This usually happens at about 6 weeks and again at 6 months of age. Moms need to know that this is NORMAL. Babies go through these growth spurts at different times.

Some mothers become worried as their breast soften after the first week or two. This is also normal. Mother's breasts should feel fuller before a feeding and softer after.

Bottle feeding is different from breast feeding. With breastfeeding a baby can refuse more milk when baby is full but with a bottle feeding, baby may continue to suck even after baby is full. This can lead to excessive calories and excessive weight gain.

Some mothers do not feel a let down. Other mothers feel one at most feedings. Everyone is different.

Babies fuss for many different reasons. There are different ways to calm a fussy baby. Swaddling baby might help. Offering the less full or empty breast as a pacifier for the baby to suckle can also calm baby. Some mothers choose a pacifier to calm the baby. However, the American Academy of Pediatrics suggests waiting till breastfeeding is well established before offering the pacifier.

A meconium stool usually occurs at least once the first day and increases in number each subsequent day. It looks black like tar and sticks to baby's skin. A transitional stool is usually seen by day 3 or 4. A mature breast milk fed stool is seen at 5-7 days. It is usually soft, yellow and seedy, often resembling loose scrambled eggs.

Breastfed babies can have many stools a day and may have a stool after every feeding. After 6 weeks this may slow. It is common for older exclusively breastfed babies to go days without a stool. But a lack of stools may be a warning sign in the early few days and weeks that the infant may mot be receiving sufficient milk. After 4-6 weeks, stools may decrease even though breastfeeding is going well. This is normal. After approximately 6 weeks some infant may go days between stools.

Most newborns will loose about 7% of their birth weight. Some infants may loose up to 10% of their body weight in the first few days especially if they have been given other fluids at birth. An infant should not continue to loose weight after the fourth day of life. Breastfed infants should regain birth weight by two weeks and if not, the pediatrician should work with mother to come up with a feeding plan that may include pumping and/or supplementing with her own milk or formula for a few days. Follow-up with the baby's doctor is important.

In the first few weeks of life it is important that baby nurses around the clock, usually 8-12 times in 24 hours (every 2 to 3 hours). If baby sleeps more than 4-6 hours at night, baby may not get enough milk to have sufficient weight gain. On the flip side there are exceptions to that rule. The important thing is to make sure that the infant is gaining weight. If the weight gain is less than ideal it is important to be waking baby to feed. Your follow up visits with the baby doctor are important.

If Mom has a sleepy baby and has difficulty getting the baby to take a full feed, mom should either hand express her milk or be instructed to pump after feedings.  She can supplement with her own milk. Some moms choose to pump and have Dad give a bottle of breastmilk in the evening.

Remember breastfeeding is a joint venture. If Mother feels full, she can also wake baby to feed and relieve her fullness.

Once a steady weight gain is established, it is not as important to wake the infant for feedings. At this point Mom can let baby wake her overnight for feedings.

The frequency and effectiveness of colostrum (Mother's early milk) removal in the first 3 days influences later milk production potential. When milk is expressed from the breast, the breast sends a message to the brain that it needs to be refilled. The brain then tells the body to make more milk. So, the most important thing to remember is when milk leaves the breast, more is replaced. If milk stays in the breast, it signals to the brain to slow down milk production.

We know that pump suction alone may not remove milk (especially colostrum) as well as the baby or hand expression. Tactile stimulation of hand expression may increase stimulation of the let down reflex. Compression of the breasts may increase the flow.

Hands on pumping information: http://newborns.stanford.edu/Breastfeeding/HandExpression.html. 

If mother is taking any birth control meds, mothers may not equate birth control with medications. Some birth control may interfere with lactation. The LAM method (Lactational Amenorrhea Method) is used to space children approximately 2 years apart. If using this method, it is important for mother to remember that she needs to exclusively breastfeed; some research suggests that if a mother is pumping in lieu of some breastfeeding this increases her chance of ovulating early and becoming pregnant. 

A mother must be breastfeeding at least every 4 hours to this be effective. Pumping at feedings does not provide the same effectiveness.

Barrier Methods provide good protection with out interfering with breastfeeding. 

Sterilization – Most common form of birth control also does not interfere with breastfeeding.

These three forms of contraception listed above are not going to interfere with breastfeeding.

The evidence from randomized controlled trials of Progestin only hormonal birth control is limited and of poor quality.  The medical consensus is to ask mother to wait until her milk is well established before using the Progestin Only method.  Since there is conflicting research on these birth control methods, it seems best to wait until breastfeeding is well established before using the hormone forms of contraception.

There is still a misconception that nipples need to be toughened. Research does not show that having a mother toughen up her nipples by either rubbing them with a towel or sandpaper (just being funny) help prevent sore nipples. 

The most common reason for sore nipples is a poor latch. When a latch problem is resolved usually the feeding are more comfortable to the mom. Once mother is already sore, some discomfort may be normal when the baby first latches but should dissipate in a few seconds.

When a mom becomes engorged the baby has difficulty latching well. Mom can hand express or pump for a few minutes before the baby latches. 

A baby with a short frenulum (tongue-tie) may cause the mother nipple soreness because the tongue may not be able to latch well and usually ends up rubbing the nipple raw. Most moms find a great improvement when the frenulum is clipped. Many ENT’s do this. (These babies can bottle feed well.)

Thrush is usually seen after several weeks of breastfeeding. Mother and baby need to be treated. Sometimes thrush is resilient and mom must be treated with Diflucan for best results.

Sometime the nipples are too large, flat or inverted. For the mothers with flat or inverted nipples, nipple shields work well for some. If a mother has very large nipples she may prefer to pump for a few days or weeks until the baby’s mouth finally grows big enough to feed well.

Poor latch is usually the number one cause of sore nipples. Correcting a bad latch usually improves the pain level of the mother immediately. Once a good latch is established,  mother can start feedings on the side that is less sore or pump for a few feedings while they heal.

Mothers can take pain medications like Tylenol to get some relief. Gel pads can be bought in most baby stores. Several companies make them.

Almost all women experience full breasts a few days after delivery. However engorgement is worse causing swollen hard breasts usually accompanied by a temperature in the mother. Express milk to soften the areola before feeding. Use reverse pressure softening. This is a techniques where moms put gentle pressure around the nipple to decrease the swelling and help evert the nipple.

Frequent feedings usually help keep the breasts from becoming engorged. It is important in avoiding engorgement to have the mom feed frequently. If the baby is not latching on well, mother can hand pump to help soften the breasts.

Mom can use Tylenol for pain relief.

Most mothers do not get thrush but when they do, they experience nipple pain and tenderness. Mother and infant need to be treated simultaneously and are usually treated for two weeks. Return of thrush is common if moms discontinue treatment early. The yeast usually responds to the use of nystatin cream. Boil any pacifiers, bras, and nipples to kill yeast.

If a baby has diaper rash his mouth should always be checked for thrush as well. Clotrimazole, nystatin and miconazol are usually the treatments of choice.

There are a few babies that have small mouths, while the mom has large nipples. Latch on my be difficult as well as impossible in the beginning. These mothers should begin to pump (using a large pump flange) and continue to try and latch infant ever few days or so. Most babies will eventually be able to latch.

Some mothers have thick, dense areola tissue which makes latching on difficult. For most of these moms the areola is only dense due to edema caused by IV’s during delivery. It may take a few days to resolve. Some moms have success with a techniques called reverse pressure technique. You can go to www.kellymom.com. for more information. Flat nipples are not always a problem especially if mom's breast tissue is soft. The baby makes his own nipple. So looks are deceiving. If a baby is unable to latch due to flat nipples, some moms have success with a nipple shield or using a breast pump a few minutes before latching the infant to her breast. In the case of the nipple shield, it is important that the mother continue to work on getting the baby onto the breast with it.

Some research suggests that the continued use of the nipple shield can cut down on milk supply. When a nipple shield is used for flat or inverted nipples is should be used for a short period of time. Moms should continue to try and latch the baby without the shield. Before using a shield, her doctor and mother should check mother's nipples. If one is able to grasp the outside of the mother’s areola, compress and form a nipple, she does not have true inverted nipples. Some mothers nipples appear flat but are easily drawn into the baby’s mouth.

Side note: Nipples shields have also been used for sore nipples or in moms that have a strong let down and the baby tend to choke on the milk. The shield slows the flow of the milk somewhat. There is much controversy about whether or not babies get “nipple confused”. What we do know is that “some” babies have difficulty learning to do both in the beginning. Other babies can go back and forth from the bottle to breast without difficulty. To avoid any unforeseen problems it is best to avoid artificial nipples in the beginning at least for 4-6 weeks until breastfeeding is established.

This little rhyme can help with positioning; "Belly to belly, chest to chest, chin to nose and touch the breast."

Putting a baby skin-to-skin will many times facilitate the infant to wake, start rooting and begin to open wide for a latch. It is important for mother to take her time and wait for the baby to open wide for the baby to latch effectively.

Listen for swallowing. Be aware of urine and stool output. A rule of thumb is one urine and one stool on the first day of life (DOL). Two urines and two stools on DOL 2. Three urines and three stools on DOL 3 etc.

Mother and Doctor will monitor weight gain. Normal infant weight gain is 1⁄2-1 oz. per day on average. Weight loss should stop after day 3 of life.

If a baby is not gaining weight, we all agree that it may be necessary to supplement. It is always most important to “Feed the Baby”. We can work on breastfeeding while the baby is being supplemented.

A supplement of formula should be treated like a medication. It should be given in doses and the goal should be to eliminate it as soon as breastfeeding is going better.

Women with previous breastfeeding problems, or potential problems may wish to meet with a Lactation Consultant prior to delivery if possible. Every baby is different and this baby may be a great breastfeeder.

Research shows that birth interventions and separation of mother and infant at birth can put mother at risk for premature weaning and low milk supply. If mother states that her breasts did not change during pregnancy, this can be a red flag and working with a Lactation Consultant can prove helpful.

Mothers need to know that frequent feedings are normal and babies do feed at night.

Breast surgery or breast trauma can sometimes affect breastfeeding success. Breast augmentation is usually not a problem with reastfeeding, however many mothers that have reduction surgery are at risk for a compromised milk supply.

Some mothers may have inverted nipples, flat nipples and/or have had nipple trauma. Engorgement that is not resolved may lead to a low milk supply.

If a baby is not latching onto the breast, the milk supply has to be preserved. Start pumping and/or hand expressing every 2-3 hours. Supplement with breast milk whenever possible. Work on getting the infant to the breast. Seek assistance as soon as possible from your doctor or a lactation consultant (LC).  Many LC’s will come to the mothers house for assistance and some insurance companies will pay for these services.

All newborns lose weight because of a normal loss of extra fluid following birth. Average weight loss is about 6% and it occurs aver a period of 2-3 days after birth. Breastfed infants should regain birth weight around 9-14 days of life days of life.

Colostrum is the yellow liquid full of antibodies and nutrition for the first days of an infants life. The amount of colostrum is measure is teaspoons and tablespoons. This is the perfect amount for the newborn infants gut. Colostrum usually changes to transitional milk at about 3-5 days.

Usually infants will take in about 1 1⁄2 to 2 ounces of milk per feeding after approximately 5-7 days. Remember that colostrum is measured in teaspoons and infants need more short frequent feeds in the first few days to stimulate more milk producation.

No perfect supplementing feeding device has been found. No method is without benefits or risks. The bottle is most common but the suck is different and may confuse the baby going back to the breast. Not all babies will be “Nipple confused” but we just don’t know which ones will so we try and avoid the introduction of a bottle nipple if possible

The cup has been shown to help preserve the breastfeeding duration among those that need frequent supplementation.

The SNS or supplemental nursing system may be the best because helps to stimulate a milk supply while receiving the supplement. The downside is that is more trouble and moms should clean it well after every use.

Each parent must decide which method is best for their family but they do need to know the benefits and risks of all supplementing methods.

The goal with using any supplement is to eventually get and exclusively breastfeeding if possible.

Mother may be able to hand express or pump between breastfeedings and supplement with her own milk. This should be the first choice. If she is not able to pump or hand express, banked milk may be a good second choice. Be aware that mothers can and do buy breastmilk over the internet. This should be discouraged because the safety of milk not pasteurized may harm baby. Donor human milk is also very expensive. It costs about $3.00 per ounce. 

The hydrolysate formula is the third choice because it avoids the exposure of cows milk protein, reduced bilirubin levels more rapidly and should convey the message to mother that this supplementing is a temporary therapy for her baby.

The 4th choice is cows milk formulaSoy formula should be a last choice. Supplementing with glucose water is not appropriate.

Remember that new research is showing that hand expression may be better at yielding more milk than pumping. This is especially true in the first few days and for mothers that are pumping for weeks at a time.

Hand expression along with pumping increases milk production.

If supplementation is necessary, offer infant expressed breast milk. Supplement a small amount in addition to breastfeedings and pumped breast milk. Monitor weight. The hydrolyzed formula may be a good choice when needing to supplement for a few feedings because infants rarely like the taste and may return back to the breast easier. This formula is more expensive.

Decrease amount of formula used while increasing breastfeedings. Still monitor weight gain. If needed, mothers can rent a scale for their home use from Medela the breast pump company.

The above information is offered as suggested guidelines. Working with your pediatrician and/or Lactation Consultant is suggested if breastfeeding presents a problem.


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