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Breastfeeding

The American Academy of Pediatrics states that “mother’s milk is the best food for a baby”. Breastmilk provides a balanced diet for a growing baby, with over 200 different constituents in a perfect proportion to support the growth and development of your baby. Breast milk is also rich in disease fighting proteins called antibodies. Many studies have shown that breastfed babies have fewer infectious illnesses than formula fed babies. The current recommendation of the American Academy of Pediatrics is that a baby should be breast fed until the first birthday.

It’s important to know how breastfeeding works in your body so you’ll understand the reasons for early, frequent feedings beginning just after birth. Breast milk production and release is controlled by the relationship between the nervous system and the breasts. When an infant sucks on the breast, signals are sent to the brain to release a hormone called oxytocin, which in turn causes the let-down reflex where milk is expelled from the breast. Once this circuit is well-established, the let-down reflex will occur when a mother hears her infant cry. Once the breast is emptied, another hormone is released, called prolactin, which helps keep the milk supply abundant.

Positioning for breastfeeding is very important. If you are a first time mother, your nurse or pediatrician can help you in the hospital to get started. The 3 most commonly used positions are the football position, the side-lying position and the cradle position.

If you intend to breastfeed, you should put your baby to the breast soon after delivery, within 4 hours if possible. Your baby should suck 5 to 10 minutes on each side every 2-3 hours. Colostrum is the first milk, or pre-milk, and is a thin, yellowish liquid high in protein and rich in antibodies. There will be about 1 ounce of colostrum produced per day in the first 2-4 days postpartum. This may not seem like a lot, but the colostrum does give the baby important antibodies and helps to get rid of the first stools, or meconium.

Once you get your baby home, you will probably be nursing every 1-3 hours. During the first 2 weeks, you should wake your baby to breastfeed if she sleeps longer than 4 hours. After this time your milk will be in and your schedule will likely be nursing every 2-3 hours during the day and every 4-5 hours at night. Most babies will nurse about 15-20 minutes on each breast. Some babies, “barracudas”, will empty a breast in 8 minutes, whereas others, “gourmands”, will empty a breast in 20-25 minutes. The stools of breast fed babies are very variable. Some babies will have 8-10 stools per day, and others may have a stool every other day. This is all normal. A breastfed stool is a little watery, yellowish, and seedy.

Common Breastfeeding problems

Mastitis

Mastitis literally means inflammation of the breasts. The inflammation is usually caused by infection with either streptococcus or staphylococcus bacteria. It is most common during the first 2 months postpartum, and is characterized by redness, pain, and swelling of the breast accompanied by fever and malaise. Treatment of mastitis requires the use of antibiotics, heat application, and nursing.

Mastitis may progress to abscess formation (localized pocket of infection) if not treated. If an abscess forms, it will require drainage by a surgeon and treatment with antibiotics. If there is an abscess in the breast, you will need to discontinue breastfeeding until the infection has cleared. You can pump and discard from that side.

Engorgement

Engorgement of the breasts occurs within the first week postpartum, usually around the 3rd to 4th day. It is caused by a rapid increase in milk production, increased blood flow to the breasts, and poor milk flow. The breasts are firm and tender. Engorgement, unlike mastitis, is notaccompanied by fever and redness.

Treatment of engorgement includes:frequent nursing, every 1-2 hoursapply heat before nursing either by hot shower or applying warm washcloths to your breasts before nursingapply cool compresses after nursingmassage your breasts while your baby is feeding–with a stroking motion toward the nippletry pumping or hand expressing some milk before feeding, this will soften the breast and make it easier for your baby to latch onmake sure that your baby has as much of the areola in her mouth as possible; this is important for proper milk flow as well as decreasing your discomfort

Cracked Nipples

Cracked, sore nipples are very common in the first week postpartum. The most common cause is improper positioning of the baby’s mouth while feeding. If your baby does not latch on properly, nursing will be painful, your nipples will become sore, and you may not produce enough milk. Nursing should not be painful. During the first days of nursing, the initial latch-on may be painful, but this pain should disappear for the remainder of the feed. If you are experiencing pain through the entire feed, this is not normal and you should elicit the help of your pediatrician or a lactation consultant.

Treatment options include:

  • feed on the least sore nipple first; babies suck hardest when they begin nursing
  • let your nipples air dry after feeding
  • at the end of nursing, allow some breast milk to dry on the nipples
  • feed for shorter periods of time, at more frequent intervals–5 minutes each breast every 1 ½ to 2 hours
  • position your baby correctly—make sure you get as much of the areola in your baby’s mouth as you can. Do not let the baby suck on the tip. Hold the breast with 4 fingers below and the thumb above the nipple.
  • change your nursing position from feed to feed
  • you can apply USP Modified Lanolin to your nipples after feeding. It does not need to be washed off before the next feed.
  • if you are having severe pain, you may need to rent an electric breast pump for a couple of days. Pumping will allow your nipples to heal, and will keep up your milk supply.

if you are experiencing stinging or burning of the nipples, you should contact your physician, you may have a yeast infection on the nipple.

Common Breastfeeding questions

How do I know my baby is getting enough milk?

Because you can’t see the milk coming from the breast while your baby is drinking, it is hard to know how much she is getting. There are several reliable indicators, though, that you can look for:

How many wet diapers is she having?

A good rule of thumb is that a newborn should have a daily total of wet diapers equal to infant age in days: (3 on day 3, 4 on day 4, etc.), after day 5, she should have 6-8 wet diapers per day. If your baby is not urinating enough during the first days of life, she will have what is called a “red brick diaper”, which represents urinary crystals, indicating he is not getting enough milk. If you see this, you should alert your physician. He may choose to supplement the baby with formula for a day or 2, and will probably refer you to a lactation consultant.

You should be breastfeeding every 1 ½ to 3 hours, or at least 8 times in 24 hours. Time the feeds from the beginning of one feed to the beginning of the next. Your baby will probably fall asleep at the second breast, and this is normal. If your baby is still hungry she will likely cry or continue to root (mouthing movement in babies indicating they are ready to feed).

Your breasts should feel full before a feeding and soft after.
Your baby’s stools should transition from the dark greenish meconium to “breast fed stools” on or around the 4th or 5th day. As stated above, a “breastfed stool” is a little watery, mustard-yellow in color, and seedy (looks a little like small curd cottage cheese). Many babies will have a stool every time they breast feed in the first weeks of life.

If you or your health care provider are concerned that your baby is not getting enough milk, a reliable indicator is weight gain. Your baby should gain about 1 ounce or 20-30 grams each day for the first couple months of life. Checking weekly weight may be warranted for several weeks if there is a question that your baby is not getting enough milk. Remember that in the first week of life, your baby will lose up to 8% of his body weight, representing extra body fluids, which he will regain by 2 weeks of age.

If you seem to have a low milk supply, the first things to try will be frequent feeding, increasing your fluid intake, and working closely with your health care provider or lactation consultant. If these interventions do not seem to be helping, there are prescription medications for the mother, such as Reglan, that help to stimulate milk production.

 

 

 

Does my baby need any vitamin supplements?

Breastfed babies may need supplementation with vitamin D, fluoride or iron, depending on each individual case.

Vitamin D is present in sunlight, fortified milk, and formula as well as salmon, sardines, liver, and herring, although your baby will not likely be eating any of the latter 4 items until at least 1 year of age. Vitamin D deficiency rickets is rare today, although a strictly breast fed infant that is not exposed to sunlight during the winter months may be at risk. Therefore, if your baby is solely breastfed, you should discuss vitamin D supplementation with your baby’s pediatrician.

 Fluoride supplements may be needed if your local water supplies have less than 0.3 ppm (parts per million) of fluoride, or if your infant is exclusively breastfed. Your baby’s doctor will likely have a chart of fluoride levels in area towns. If not, you can contact your local health department; they will also be able to help you arrange to have well watered tested. If needed, fluoride supplements are begun at 6 months of age.

Iron supplements are usually not needed except in breastfed babies that are not started on solids by 6 months of age. Babies are born with good stores of iron. These stores begin to diminish around 5-6 months of age and therefore need to be replenished in the diet either via formula or iron fortified foods. The iron in breast milk is very bioavailable (readily absorbed by the baby), but the amount is not very high, and this is why solely breastfed babies beyond the age of 6 months need iron supplementation. Infant cereal especially is iron fortified, and vitamin C aids the absorption of iron. Therefore, if you mix your baby’s morning cereal with vitamin C containing juice or pureed fruit, this will be an excellent source of iron.

When can I start to supplement with a bottle?

In general, you can start to supplement with a bottle (preferably with breast milk) after 2 to 3 weeks of age. If you introduce a bottle on a regular basis before this time, your baby may experience nipple confusion. Basically, it is harder to feed from the breast than the bottle and if your baby is given the choice early on, she will likely choose the bottle. In cases where a bottle needs to be given to babies in the first days of life due to poor weight gain or not enough wet diapers (or “red brick diapers”), the bottle is usually given after breastfeeding, every other feed for 1 or 2 days. In this scenario, you will not create nipple confusion.

I gained a lot of weight during my pregnancy, when can I start a weight loss program?

A breastfeeding mother’s diet is very important. You should not start a drastic weight loss reduction program while breastfeeding. You should eat a well balanced diet and continue to take your prenatal vitamins. Below are some general guidelines for food choices for breastfeeding moms. If you are on a restricted diet of any kind or are vegetarian, you should consult a nutritionist for a balanced meal plan.

Food guidelines for breastfeeding mothers:

  • You will need an extra 400-500 calories per day
  • Eat plenty of whole grain foods like, breads, brown rice, bran products, whole wheat bagels, whole wheat pita bread, whole grain cereals
  • Be sure to get 1200-1500 milligrams of calcium per day from milk or milk products, calcium enriched orange juice, green leafy vegetables, canned salmon or canned sardines, and Tums chewable tablets have either 200 or 300 mg of calcium per tablet
  • Eat lots of vegetables and fresh fruit
  • Eat iron-rich foods like meats, eggs, dried fruit, nuts, legumes (peanuts, beans, lentils, dried peas, chick-peas), liver, spinach, soy products, blackstrap molasses, carob and iron-fortified whole grain products
  • Drink an 8-10 ounce glass of fluid (water, juice or milk) each time you breast feed (about 2 quarts or 64 ounces per day)
  • Limit sweets and high-fat foods. Your diet should not contain more than 30% of the calories from fat. Olive oil, canola, safflower, and sunflower oils are preferable to coconut or palm oil
  • Limit caffeine intake. Coffee, for example, should be limited to 2 cups or less per day; more than this may make your baby irritable and jittery. (For more information, see “caffeine” under separate heading)

Avoid alcohol and cigarettes. An occasional glass of wine or beer is OK, but you shouldn’t drink alcohol on a daily basis

All of a sudden my 5 week old is looking to feed every 2 hours again, is this normal?

  • Your baby is going through a growth spurt. Growth spurts occur at 10-14 days, 3-4 weeks, 6 weeks, 3 months, and 6 months.

How long can I keep my pumped breast milk in the refrigerator?
Breast milk can be stored in the refrigerator for 48 hours, and in a 0 degree freezer for 6 months. For storage in the freezer, do not fill the bottle more than ¾ full. Breast milk which has been frozen can be thawed in the refrigerator and used within 3 hours or thawed under warm tap water and used within 30 minutes. Label the bottles with the date pumped, and use the oldest first. After feeding your baby, discard any remaining milk.

 

 

I am returning to work and need to pump, does it matter which pump I choose?
Which pump to choose will depend on your individual needs. If you plan to pump only occasionally for the purpose of having a bottle for an outing or for relief of engorgement, you probably will be fine with a hand-pump or a small electric or battery powered pump. If you intend to pump on a regular basis for 1 or more months, you should either rent or invest in one of the large electric pumps. You will hear many stories of women who have gone through 2 or 3 pumps before finding the one that is right for them. Therefore, before wasting money, do some research, ask a friend, or call your local La Leche League or a local lactation consultant.

How should I wean my baby?
Currently the AAP recommends breastfeeding for at least 1 year. Some women will choose to breastfeed longer and some shorter. The following guidelines should be helpful when you are ready to wean.

  • Your goal should be to wean over about 3 weeks. Replace 1 meal of breast milk with formula or juice every 3 to 4 days. The last feedings to go will likely be the morning and late evening feeds
  • Give solids or a bottle or cup of formula before the breast milk
  • Decrease your fluid intake
  • Don’t express milk with an electric pump, this will stimulate milk production. If you are uncomfortable, you can express a few drops of milk by hand or with a hand pump.
  • Don’t take pills to decrease your milk supply
  • Remember, introduce a cup around 6 months, and wean from the bottle around 12 months

Contraindications to breastfeeding

Maternal factors:

 

  • Maternal infection with tuberculosis (TB)
  • In the United States, maternal infection with HIV/AIDS
  • Maternal medications such as antihypertensives, chemotherapy, antithyroid medications (excluding PTU), and sedatives. It is a good idea to discuss any medication you are taking or plan to take with your doctor.
  • Drug abuse

Newborn factors:

  • Metabolic disorders such as PKU, galactosemia, or lactose intolerance
  • Cleft palate (you may attempt to breast feed with the help of a lactation consultant, but in most cases of cleft palate the baby will need to bottle feed with a specialized bottle)

If you are unable to breastfeed due to one of the above factors, or other issues, remember that formulas exist and have been created to be as close to breast milk as possible. Also remember that millions and millions of babies have been and are being formula fed.