Choosing to Breastfeed

You have most likely heard of the benefits of breastfeeding. The World Health Organization and the American Academy of Pediatrics, as well as other organizations such as La Leche League, all promote breastfeeding as best for your baby. While infant formulas are safe, effective, and vastly improved over previous formulations, breast milk is superior in that it is usually easier to digest, nutritionally complete, and contains maternal antibodies that help fight disease which are not able to be reproduced in even the best infant formula. Additionally, breastfed babies have a lower incidence of sudden infant death syndrome (SIDS).

Hormonal changes in the mother who breastfeeds are reported to improve healing and slow bleeding after delivery. For some, it is important to know that breastfeeding is less expensive than formula feeding, even for those who purchase a high quality breast pump. Also, breastfed babies usually spend less time at the pediatrician’s office for illnesses due to the passive immunity gained from the mother, especially in the first few weeks to months. Most mothers are able to breastfeed and most babies will breastfeed without difficulty. However, there are some mothers for whom breastfeeding may not be the best choice. Occasionally, your doctor or pediatrician may recommend formula feeding if you are on certain medications or have certain medical conditions.

It is generally best to allow two weeks of exclusive breastfeeding to establish a good feeding relationship with your baby. However, as important as exclusive breastfeeding is, it is not the only option. Feeding your baby an occasional bottle of formula or expressed milk after the first two weeks of breastfeeding should be possible. This will allow other family members to participate in caring for the baby and give you a much needed break. This may be especially important if you have twins, triplets, or a high-needs infant.

What to Expect in the Hospital

Generally, if your labor and delivery were uncomplicated, you should be able to initiate breastfeeding within the first hour after delivery. You should communicate with your health care team your desire to breastfeed and how soon you wish to start. Often, visitors wish to come into the room as soon as possible. You should discuss any special wishes regarding visitors with your nurse and doctor. Some newborns are ready to breastfeed within minutes of delivery, while others show no interest in the breast for hours. Offering the breast to your baby in a quiet room with limited visitors is usually more comfortable for the mother.

Your needs will vary and it is important to be flexible. Some new mothers benefit from one to two hours alone with their infants prior to letting visitors in the room, but this is not mandatory for a successful breastfeeding relationship. It is important that your family and friends understand you may need to be alone at frequent intervals to feed the baby, as often as every three hours and for as long as an hour at a time. You should also remember that you will require some private time for special treatments, medications, or discussions with your nurses and/or physicians.

In the early days, your baby will be getting colostrum from your breasts. This is exactly what the baby needs at this time. Most hospital stays are one to two days for a vaginal delivery. In this situation, you will most likely be producing colostrum until you leave the hospital. Breastfeeding your baby on demand will give you the most successful experience. If the baby is awake, chewing on his hands, or rooting (turning his head and opening his mouth), he is ready to breastfeed. It is very common for babies to “cluster feed” – feeding every one or two hours for several feedings and then taking a longer four to six hour break to sleep. This is normal. Use these longer breaks to rest or snuggle with the baby. As long as the baby is healthy, has the appropriate number of wet diapers, and sleeps between feedings, he should be getting enough to eat.

It is very common for newborns to lose some weight in the early days of life. You will notice that the baby has a very dark, sticky stool called meconium. Some babies stool once a day, others will pass meconium with every feeding. Babies are also born with extra fluid stores. Passage of the meconium and extra fluid accounts for the weight loss in the early days of life. If your baby does not lose too much weight too fast, and has regained her birth weight by two weeks of age, then breastfeeding is going well. Your health care providers will usually weigh the baby often and alert you to any problems. They will also wish to examine the baby. Try to work with them to schedule or allow these exams at a time when the baby is getting ready to eat but not too hungry.

If you have a boy and he is circumcised, you may notice that he is especially tired after the procedure. This is common. Continue to breastfeed on demand, but alert your nurses to any concerns you may have.

One common experience is the second night “fussies.” At about 12-24 hours of age, many babies will wake up frequently, but fall asleep as soon as they are put to the breast. This pattern will repeat as soon as you try to lay the baby in the crib. Ask the nurses or your support person to help you by snuggling with the baby, offering the pacifier to the baby if you desire, or soothing the baby while you rest. You may also try putting the baby to the breast and gently unlatching the baby by sliding your finger into his mouth to break suction after he has entered deeper sleep. Easing the baby into the crib may be easier at this point.

Special Cases

If you have had a complicated labor and delivery, or if your baby requires special care, you may not be able to initiate breastfeeding for hours, days, or, in rare cases, for weeks, or it may become necessary to supplement your newborn with infant formula. You may be concerned about bonding with the baby or how this will affect your breastfeeding experience, especially if you are separated from your baby. In even the most complicated cases, it is usually possible to begin using the breastpump within 24 hours of delivery. Using a double electric pump for 15 minutes every three to four hours will encourage milk production. You will probably express very small amounts of colostrum for a few days (as small as a few tablespoons each day). This is normal. Any expressed milk can be saved for feedings.

When your baby begins oral feedings, these are usually done with syringes, feeding tubes, or finger feedings by staff or parents, and will advance over hours to days to feedings at the breast or by bottle. Try to rest as much as possible, and focus on other ways of caring for and bonding with your baby as the occasion allows.

What to Expect at Home

If you are discharged home with your baby within two days, you will most likely not be producing milk. This is normal. By the fourth or fifth day after delivery, you will notice that your breasts are engorged, which means they are full of milk. You may also feel very irritable and cry easily. Often, the baby will have difficulty latching because of the engorgement. It is a good idea to gently express some milk with your hand or massage your nipple until it is soft enough ftor the baby to latch. Usually, the engorgement will resolve in 24-72 hours. Pumping at this time will only increase your milk supply and prolong the engorgement. However, if you are unable to tolerate the discomfort, you can try pumping just enough to feel better. This will also make it easier for the baby to latch. It is important to remember that this is a difficult, stressful time for some new moms, as they may feel overwhelmed. It usually only takes one to two days before the engorgement has passed and you will be feeling more confident in your breastfeeding abilities.

You will probably also experience nipple discomfort if you are having difficulty getting the baby to latch. Applying lanolin cream to your nipples after feedings, using breast shells to keep your bra from rubbing on your nipples, and avoiding soap on your nipples may help with the discomfort. Finally, your hospital or pediatrician may be able to provide advice over the telephone if you need it. See if your hospital or pediatrician has a lactation consultant or nurse line where you can ask for advice.

Special Cases

If your baby was premature, or if you had a Cesarean delivery, you may find recovering at home more difficult than you expected. Try to arrange for help from family and friends prior to leaving the hospital and allow people to help you. Your own recovery, combined with the demands of caring for a newborn, can be tiring. You may have frequent follow-up visits for yourself and/or your baby. Some newborns may require special medications or supplemental feedings. Often, you will have to return to the pediatrician’s office several times in the first few weeks. Your pediatrician or care provider should ask you about breastfeeding and provide information and support as well as evaluate the baby’s growth, frequency of feedings, wet diapers, and general well-being. You should have a support person present for these visits. This support person can help you remember pertinent information, provide assistance, keep records, and notify other family and friends about your and the baby’s progress.

Helpful Tips

Breastfeeding is a natural process and can come easily to some women while others may need help. Almost all breastfeeding mothers require some type of support and encouragement. Here are a few helpful tips:

• Allow the nurses to help you as much as you need it while in the hospital. You will need at least one hour of quiet time to feed the baby and care for yourself every two to three hours.
• Try to feed on demand. Look for early feeding cues, such as rooting, sucking on hands or fingers, or quiet awake times. Your best success will be if the baby initiates the feeding. Often, these periods will last only 20 minutes, so it’s best to initiate the feeding as soon as possible.
• Most babies are very sleepy in the first 12-24 hours after birth. Try waking the baby every three hours during the daytime if he does not awaken on his own. If the baby is ill-appearing or lethargic, alert your nurse or pediatrician immediately.
• Check for wet diapers and stools. In the first two to three days, it is normal for the baby to have two to three wet diapers and at least one stool in a 24 hour period. Once your milk really comes in or by the fourth day, the baby should have six to eight wet diapers in a 24 hour period. This should reassure you that feeding is going well.
• Before you begin feeding, make sure you are in a comfortable position. It is helpful to have a large glass of water nearby, as you will probably notice that you become thirsty while feeding. Drinking plenty of water is important (usually two liters or more a day).
• Bring the baby to your breast in the hold that is most comfortable for you – cradle, football, or cross-cradle holds are most common. If you are able, you can breastfeed very comfortably in a side-lying position. Tickle the baby’s lips with your nipple. When the baby opens his mouth, bring his head to your nipple. Do not stretch your breast to reach his mouth. Most babies begin sucking immediately. Relax your shoulders and arms and rest as much as possible during the feeding. Allow the baby to suckle as long as he desires. After 20 minutes, if he is still feeding, gently break suction with your finger and try to burp him. Then allow him to nurse on the other side if he wants to. Some babies will nurse for 20 minutes on each side for every feeding. Some babies will be full after 10 minutes of feeding, but feed more frequently. Getting to know your baby takes time.
• Burp your baby after the feeding by gently patting her back and holding her upright for about 10 minutes. This will also help prevent the baby from spitting up. A small amount of milk may come up with a burp. Sometimes the baby will regurgitate some milk and swallow it without problem. This should subside as the baby gets older.
• Remember which side you started the feeding and start the next feeding on the opposite side.

It is usually best to change your baby’s diaper after a feeding instead of before the feeding.

When to Call Your Doctor

You should call your obstetrician or midwife if you have signs of mastitis. This is more likely if you have cracked and bleeding nipples and feeding difficulties. These signs include:

• Severe pain in the breast.
• Redness or streaking in the breast.
• Chills and a fever of 100.4°F or above.
• Flu-like symptoms including malaise, aches, and pains.

Call your pediatrician for questions or concerns, or if the baby has any of the following:

• Less than three wet diapers in 24 hours by the second day.
• Less than six wet diapers in a 24 hour period by the fourth day.
• Refusal to eat for two feedings.
• Vomiting (occasional spitting up should not concern you).
• Difficulty waking for feedings.
• Very irritable or inconsolable.
• High-pitched cry.
• Fever of 100.4°F or above.
• Yellow color of the skin or eyes (jaundice).

If you think the baby is very hungry or not getting enough to eat.