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A guide for breastfeeding A GREAT START

When it comes to breastfeeding, even though there are things that come naturally, both you and your newborn need to learn how to successfully breastfeed. Do not be afraid to reach out. Engage a lactation consultant to get the help you need. Now more than ever before, there are resources available to you to make this a wonderful experience. This book is designed to answer some basic questions you may have. You will also have instructions from your healthcare provider on specifics for your newborn. Enjoy this time—your baby will develop and grow right before your eyes! Thank you to the many people and organizations that participated in the production of this publication. Their willingness to share their personal experiences and professional expertise with us is beyond what words can express.

This publication is designed to provide helpful information on the subjects discussed. The information provided by Customized Communications is not intended to replace the professional medical advice from your healthcare provider. Use this book as a resource only. For diagnosis, treatment and individual care contact your health professional.

© 2001 Customized Communications, Inc. Arlington, Texas • 1-800-476-2253 • All Rights Reserved Reviewed 7/2016, 2/2017, 7/2017, 5/2018, 7/2018

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Table of Co ntents

4 Getting Started

19 Helpful Tips at Home

37 Going Back to Work and Continuing to Breastfeed The Last Three Months of Pregnancy 37 First Weeks at Home 37

Steps to Breastfeeding 4 5 Benefits of Breastfeeding Exclusive Breastfeeding 5 6 Skin-to-Skin Contact 7 Rooming-In 8 Preparing for Breastfeeding Breast Size and Nipple Shape 8 9 How Breast Milk is Made Milk Ejection Reflex 9 Supply and Demand 9 10 Types of Breast Milk Colostrum 10 Transitional Milk 10 Mature Milk 10 11 Breastfeeding Relationship Anatomy of the Breast 9 Physiology of the Breast 9

First Few Days at Home 19 19 Supporting Breastfeeding 20 Breastfeeding Challenges Cluster Feeding 20 Sleepy Baby 20 Growth Spurts 20

Baby is About Four Weeks Old 37 Three to Four Weeks Before Returning to Work 37 Five to Seven Days Before Returning to Work 38 The Day Before Returning to Work 38 Day One as an Employed Parent 38

Sore Nipples 21 Engorgement 22 Reverse Pressure Softening 22 Blocked Ducts 23 Mastitis 23 Breast Surgery 24 Nursing on the Go 24 Nursing Strike 25 Fungal Infections 25 Breastfeeding Multiples 26 Breastfeeding When Your Baby is Premature 28

Evenings and Weekends 38 Breastfeeding Checklist 39 Artificial Baby Milk (Formula) and Artificial Nipples 39 40 Baby’s Daily Feeding Record 43 Glossary 44 Bibliography

Breastfeeding When Your Baby Needs Special Care 28 29 Safe and Healthy Breast Milk Facts Alcohol 29 Smoking 29 Medications 29 30 Nutrition and Fitness Nutrition 30 Healthy Eating While Breastfeeding 30 Weight Loss 31 Exercise 31 32 Breast Milk Expression Expressing Breast Milk 32 Breast Pumps 32 Hand Expression 33 How Often to Express 34 Storing Breast Milk 34

Breastfeeding When and How 11 Baby Led Feedings 11

12 Feeding Cues

Please Note: All words highlighted in BLUE are clearly defined in the glossary.

HowMuch Can My Baby’s Stomach Hold 12 13 Positions for Breastfeeding Laid Back 13 Cradle or “Madonna” Hold 13

Cross-Cradle or Transitional Hold 13 Side-Lying Hold 14 Clutch or Football Hold 14

The information in this booklet is for general reference purposes only

and cannot be relied upon as a substitute for medical care. You and your baby should have regular check-ups, as well as consult with your healthcare provider about any special health questions or concerns. Every person is unique and may require a special treatment program.

15 Latch-On

Correct Latch 15 Taking Baby Off the Breast 15

16 Burping 16 How Do I Know if My Baby is Getting Enough to Eat Positive Signs 16 Baby is Satisfied 17 Weight Gain 17 Breastfeeding Tips 17 Newborn Feeding Patterns 18

Human Milk Storage Guidelines 34 Cleaning Breast Pump Parts 35 Sanitize Your Breast Pump Parts 36


Getting Started Choosing to breastfeed in order to give your baby a great nutritional start can be a little overwhelming. Yes, breastfeeding is natural, but it is also a learned skill. An important step that you can take in assuring your success with breastfeeding is to learn the facts and to understand the principles before the birth of your baby. Motivation, knowledge and practice are keys to helping you meet your breastfeeding goals. You can also find support and information from different types of health professionals, organizations, classes or support groups. Attending classes or groups will allow you to: • Share concerns Health professionals who can help with breastfeeding International Board Certified Lactation Consultants (IBCLC) are professionals with knowledge and skills to support breastfeeding. IBCLCs have specific education and clinical experience in breastfeeding and must pass an exam to become certified. They can help with comprehensive breastfeeding issues and answer complex questions. Certified Lactation Counselors (CLC) and Certified Breastfeeding Educators (CBE) have special training and experience in helping breastfeeding mothers and babies. They can help with basic breastfeeding challenges and questions. Steps to Breastfeeding Have your baby placed skin-to-skin on your chest immediately after giving birth. • Breastfeed as soon as your baby is ready. • Gain self-confidence • Build a support system • Work through issues • Learn tips • Receive encouragement

• Let your baby stay in the room with you at all times so that you can breastfeed often. • Avoid pacifiers until your milk is in and your baby is latching well to your breast. • Ask staff not to give a pacifier, sugar water, or formula unless there is a medical need. • Have confidence in yourself and your commitment to breastfeed. • Seek help from a lactation consultant if needed.

These steps can help you start a great breastfeeding relationship. Each step is explained in-depth on the following pages.


Benefits of Breastfeeding There are many benefits of breastfeeding, especially exclusive breastfeeding. For however long you choose to nurse, your baby’s immune system benefits greatly from breast milk. The following are just a few benefits of breastfeeding for you and your baby: For Baby: • Easily digested. • Has all the nutrients needed. • Has protective effects against SIDS. For You: • Convenient and cost-effective. • Helps the uterus return to its normal size faster.

• Promotes postpartum weight loss. • Less likely to develop breast, uterine, endometrial and ovarian cancer. • May reduce the risk of heart disease. • Decreases insulin use in moms with diabetes. • Lowers risk of osteoporosis later in life. • Decreases risk of postpartum bleeding.

• Protects against gastrointestinal disturbances, allergies, ear and lower respiratory infections. • May reduce the risk of certain chronic diseases and infections like diabetes and hypertension. • Protects the gut from germs and diseases. • Changes to meet your growing baby's needs.

Exclusive Breastfeeding Breast milk contains all the nutrients an infant needs in their first six months of life. Breastfeeding exclusively during that time will help them achieve optimal growth, development and health. Exclusive breastfeeding means that the infant receives only breast milk. No other liquids or solids are given – not even water. The only exceptions are oral rehydration solutions, or drops/syrups of vitamins, minerals or medicines. The American Academy of Pediatrics (AAP) recommends: • Exclusive breastfeeding for about the first 6 months of life. • After 6 months and until the infant is 1 year old continue breastfeeding while gradually introducing solid foods. • After 1 year continue breastfeeding as long as mutually desired by mother and infant. Tips to help: • Room-in with your baby in the hospital and room-share at home. • Put your baby skin-to-skin as much as possible. • Let your baby breastfeed often by responding early to your baby’s feeding cues. • Prolactin levels are highest at night, stimulating milk production, so take advantage of those feedings. • Avoid formula, unless there is a medical reason, it can interfere with breastfeeding and your milk production. • After feedings, hand express and give any extra milk to your baby. • Find support through friends, support groups or play groups. • Contact a lactation consultant if you are having problems breastfeeding. • Avoid pacifiers until your baby is latching on well, usually 3 to 4 weeks.

The World Health Organization (WHO) also recommends exclusive breastfeeding for 6 months. After 6 months a baby should receive foods with breast milk until age 2 or older.


Skin-to-Skin Contact At birth, your baby may be placed directly on your chest. While you are holding your baby skin-to-skin, a member of the healthcare team will dry your baby. They will check your baby over, and cover you and your baby with a warm blanket. Now the bonding can begin. The connection of your bare-skinned baby lying directly on your skin is called skin-to-skin contact and gives you and your baby time to get to know each other. This initial snuggling also has very important health benefits. According to the American Academy of Pediatrics (AAP), the best start for breastfeeding is when a baby is kept skin-to-skin immediately after birth and until the first feeding has finished, or as long as desired. The baby’s sense of smell allows them to find the breast to begin the initial latch-on . Research has shown that skin-to-skin babies breastfeed better and stay awake during the feeding. In addition, babies who had skin-to-skin contact are more likely to exclusively breastfeed.

Benefits of skin-to-skin contact Babies: • Breastfeed better. • Cry less and are calmer. • Stay warmer. • Have better blood sugar levels. • Have more stable and normal heart rate and blood pressure. • Are protected by some of your good bacteria .

Parents: • Breastfeed more easily. • Learn cues that your baby is ready to feed. • Bond more with your baby. • Gain confidence and contentment in caring for your baby.

Proper position for safe skin-to-skin contact Remember: Babies should always be pink in color and respond to stimulation. Babies are usually calm and relaxed while skin-to-skin. • You should be semi-reclined or upright and alert, or have an alert adult at the bedside helping. • Your baby is high up on your chest in a “kissable” position and laying in the middle of your chest. • Your baby’s head is turned to one side with mouth and nose visible and chin in a neutral position (not slouched). • Your baby’s arms and legs are flexed-in tight to the side of their body.

Keep in mind other family members can bond with the new baby through skin-to-skin contact. This contact can create special bonds with the entire family.



Years ago, babies would spend most of their hospital stay in the newborn nursery. Today, parents, as well as the healthcare team, know the benefit of babies staying with their families as much as possible. When you keep your baby in the room with you, it is called Family-Centered Maternity Care . One nurse cares for you and your baby together. You may hear this called rooming-in or rooming-together. Your baby can recognize your voice, smell and heartbeat. Having your baby with you helps you both relax. It also gives you opportunities to learn about your baby’s behaviors and what they mean. Benefits of rooming-in for parents: • You make breast milk faster, and more of it. • You can learn to recognize your baby’s feeding cues ( rooting , opening mouth, sucking on tongue, fingers, or hand). • You are able to learn what your baby’s cues are (sleepy, stressed, in need of quiet time, hungry). • You are better rested. • You are less likely to have “baby blues” and postpartum depression.

Rooming-in helps you prepare for going home as you learn how to rest and gain confidence in taking care of your baby.

Benefits of rooming-in for babies: • They breastfeed sooner, longer, and more easily.

Rooming-in is so valuable that the AAP encourages parents to also do it at home. They recommend rooming-in until the baby is at least six months old or, ideally, one year.

• They have better sleep quality. Babies will develop a more regular sleep/ wake cycle earlier, and may transition more easily to day/night routines. • Their body temperature and blood sugar levels are more stable.

• They cry less and can be soothed more quickly. • They have lower levels of stress hormones . Safety tips for rooming-together in the hospital: • Call for help anytime.

• Remember –NEVER leave your baby unattended or alone for any reason. • Pull the emergency cord or push the call button if you need help from your healthcare team. • When you need to use the restroom or shower, and you are alone, wheel the crib to the restroom door and keep it open, so you will be able to see and hear your newborn. • Keep your baby close to your hospital bed – the furthest point away from the doorway. • Do not give your baby to anyone you do not know. All personnel should properly identify themselves.

Your hospital will have special security procedures in place that are there to protect your baby. Make sure you follow them.


Preparing for Breastfeeding

There is very little that you need to do to prepare for breastfeeding. Your body has already done most of the necessary preparation. Prenatal suggestions: • If leaking colostrum , you may want to purchase breast pads. The pads may be either disposable or washable. Do not use a “mini-pad” or breast pads with plastic backing. They prevent air from being able to circulate and may cause nipple soreness. • Have someone knowledgeable about nursing bras help you purchase a well-fitting bra. • Be careful about underwire bras. The wires may place pressure on the ducts and cause a blockage of milk if not properly fit. • You may need to buy a bra that is 1 to 2 cup sizes larger toward the end of your pregnancy, although wearing a bra is not necessary. • Contact your insurance provider about coverage of breastfeeding support. • Avoid using soaps, creams or lotions on your nipples. Breast Size and Nipple Shape

Surround yourself with those who give positive encouragement.

Some people worry about their breast size, shape, or nipple type. Breast size is determined by the amount of fatty tissue that is in them. Milk is made in the glandular tissue of the breast, not the fat tissue, so breast size does not determine how much milk you can make. If you are concerned about your breast size or shape, contact your healthcare provider or a lactation consultant.

It is possible to have a nipple that is inverted (pointing inward) instead of pointing outward. Nipples can sometimes be flat and not protrude at all. Hormonal changes during pregnancy increase the skin’s elasticity, so flat or inverted nipples may protrude more after birth. Remember, babies breastfeed – they do not nipple feed. Proper positioning and latch techniques can help the baby latch onto the breast. Early and ongoing support and skilled breastfeeding assistance can help you reach your breastfeeding goal. If you have, or suspect you have, either inverted or flat nipples, talk with your healthcare provider or lactation consultant for advice. This should not discourage you from breastfeeding.

Normal Nipple

Flat Nipple

Inverted Nipple


How Breast Milk is Made

Anatomy of the Breast Your breast may become fuller and tender as the alveoli cells get ready to make milk. This can happen during or after your baby is born. By week 16 of your pregnancy your breasts are capable of making milk. Besides the alveoli cells, breasts are made of glands, ducts and fatty tissue. The nipple has tiny openings for milk to flow through. These tiny openings are surrounded by muscular tissue that causes the nipple to stand erect when stimulated. Circling the nipple is an area of darker skin called the areola . This area will become darker and larger during pregnancy due to hormonal changes. The areola contains pimple-like structures near its border that are called Montgomery glands . These glands secrete an oily substance to lubricate and cleanse the nipple area. Physiology of the Breast

Fatty Tissue


Milk Ducts



When the placenta is delivered, the level of the hormone progesterone decreases. This sudden drop signals the body to begin making breast milk. To continue making milk, the body needs to keep receiving signals from hormones. When the baby begins sucking, this tells your brain to produce two other hormones, prolactin and oxytocin . Prolactin signals the alveoli to make milk. Oxytocin causes the cells around the milk glands to contract and squeeze the milk down the milk ducts and out the nipples. This is called let-down or milk ejection reflex . It may take a minute to several minutes of sucking by the baby until the milk ejection reflex occurs. Some mothers only know that their milk has let down by seeing milk in the baby’s mouth or the other breast leaking. Milk Ejection Reflex Sensations of let-down that you may notice: • Tingling sensation. • Warm upper body sensation. • Feeling your breasts become full. Things that may cause milk let-down: • Your baby crying.

• Seeing other babies. • Thinking of your baby. • Massaging your breast gently before using a breast pump.

Supply and Demand Milk production is regulated by supply and demand. The more milk your baby takes from your breast, the more milk you will make. An emptier breast also makes milk faster than a full one. You will keep your milk production up by breastfeeding your baby as soon as possible after birth and 8 or more times in 24 hours, including at night.

The sensations commonly associated with let-down may not be felt until your milk is in greater supply.


Types of Breast Milk

Colostrum Colostrum is the first stage of breast milk that develops during pregnancy and lasts for a few days after the birth of the baby. It is also much thicker than the milk that is produced later in breastfeeding. Colostrum is high in protein, fat-soluble vitamins, minerals and immunoglobulins . Immunoglobulins are antibodies that pass to the baby and provide protection for the baby from a wide variety of bacterial and viral illnesses. Facts about colostrum:

• Commonly called “Liquid Gold”. • Can be yellow to clear in color. • Easily digested. • Serves as a laxative and helps clear the baby’s intestinal tract. • Very high in protein. • Contains antibodies which help the baby fight infection. • Coats the stomach and intestines and protects against any invading organisms.




Thick, yellow-colored milk, high in protein, antibodies and some vitamins and minerals.

Thin and white in appearance. Composition is approaching mature milk .

More watery appearance, slight bluish to white in color.

Transitional Milk Transitional milk occurs as your milk changes character and increases in quantity. When you breastfeed regularly, your breasts will be stimulated to produce transitional milk. The content of this milk includes high levels of fat, lactose and water-soluble vitamins. This milk contains more calories than colostrum and is very high in protein content. Mature Milk Mature milk is mostly water, which is necessary to maintain the correct fluid balance for the infant. The rest is comprised of carbohydrates, proteins, and fats that are necessary for both growth and energy. It is also composed of wonderful immunologic properties. These properties do not disappear, but remain throughout breastfeeding.


Breastfeeding Relationship For many people, breastfeeding is a new experience. It is for the baby as well. As a new parent, you may tend to have unrealistic expectations of yourself and your newborn. Even though a baby can suck, swallow and breathe by reflex, they have to LEARN to eat. Please know that you both will learn together through trial and error. BreastfeedingWhen and How

Research has shown that babies placed skin-to-skin right after birth will instinctively crawl to the breast, become acquainted, latch on and begin suckling. This breastfeeding will generally occur within the first hour to two hours after birth. After this intense time you and your baby may fall asleep. Be sure you have someone in the room with you to make sure you both stay safe during skin-to-skin. Baby Led Feedings There are no set times to feed your baby. Instead, you will follow their feeding cues. Feeding times will vary throughout the day, and no two days will look alike. You may find that you breastfeed 3 hours after you started that last feeding. Sometimes it may be only one hour later. Your baby may feed 15 to 20 minutes on each breast – possibly shorter or longer. Your baby will let you know what they need. See page 18 for newborn feeding patterns in the first week.

Your baby is born with the instinct to suck. It is important for that suckling to be done at the breast in order to ensure an adequate milk supply and proper nutrition for your baby. If your baby sucks on a pacifier, their desire to suck can be satisfied. However, they do not get any nutrition from a pacifier, and your breasts do not get the stimulation they need for your body to make milk.


Feeding Cues When babies are ready to breastfeed, they will show feeding cues (signs that they are ready to feed). Keep your baby in the room with you and place them skin-to-skin on your chest often. This will help you learn your baby’s feeding cues and respond quickly. Your baby may be too upset to breastfeed while crying. In this case, calm your baby first by gently rocking side-to-side, or try skin-to-skin contact.

Crying (late cue) frantic movement

Rooting: Baby’s open mouth searching side- to-side for the breast

Hands to mouth and stretching

Tongue thrusting and fidgeting

Lip smacking

How Much Can My Baby’s Stomach Hold? Baby’s tummies are small and they need to be fed often so they can grow. It will take a lot of feeding to double their birth weight within 4 to 6 months. Full-term, healthy infants have the ability to regulate their milk intake when they are fed on cue. It is common for babies to feed often during the first few days. This helps bring in a good milk supply.

Approximate Newborn Stomach Size

DAY 1 Size of a grape 5 - 7 ml 1 - 1½ teaspoon

DAY 3 Size of a cherry tomato 22 - 27 ml 1½ - 2 tablespoon

DAY 7 Size of an apricot 45 - 60 ml 1½ - 2 ounces

At 1 month newborn tummies are the size of an egg and hold 80-150 ml (3-5 ounces).


Positions for Breastfeeding There are different positions to hold your baby while nursing. It is important to know the different options for holding your baby for a feeding. This will allow you to choose which works best for you and your baby. Comfortable positioning of your baby is important for milk to transfer effectively. Laid Back This natural position is based on a semi-reclined position that is comfortable for both you and your baby. In this position, you are encouraging your own, as well as your baby’s, natural instincts. With very few rules, this position allows your baby to get a better latch and helps to relax you as well. Sit where you can comfortably recline with good support of your head, shoulders and arms. • Let your baby snuggle into your chest. Gravity will help them stay close. • Place the front of baby’s body to the front of your body. • Let your baby’s cheek rest close to your breast. Your baby may start squirming and bobbing their head toward your nipple. • Support your baby's neck and shoulders with one hand and their hips with the other. • Follow your baby’s lead. When you see their chin hit your breast you may see them open their mouth and latch on. • Stay calm and relaxed as your baby seeks your breast, to allow them to follow their instincts. Cradle or “Madonna”Hold This classic hold is a commonly used position that is often found to be comfortable for many mothers. • Hold your baby in your lap at breast level. You can place your baby on top of a pillow for better support and comfort. • Your baby's nose should line up with your nipple. • Extend your forearm and hand down their back to support their neck, spine and buttocks. Support this arm with a pillow for your comfort, if you wish. • Your baby's ear, hip and knee should be in alignment facing toward you. You This hold differs from the cradle hold in that your arms switch roles. If you are feeding from the left breast, you will use your right arm to hold your baby. • Hold your baby along the opposite arm from the breast you are planning to use. • Turn their body so that their chest and tummy are directly facing you. • Support the base of their neck loosely with your fingers. This allows the palm of your hand to support the baby’s shoulder blades and back. • Place a pillow on your lap to help support the baby and get them to the level of your nipple. can tuck their lower arm under your arm. Cross-Cradle or Transitional Hold

You will be amazed at how just a slight adjustment in positioning can make a huge difference in comfort for you and your baby.

Laid Back

Cradle or “Madonna” Hold

Cross-Cradle or Transitional Hold


Side-Lying Hold Lie on your side and place pillows all around you to make it comfortable. (One behind your back, between your legs and under your head.) • Pull your baby close and facing you. • You can support your baby's back with your forearm or place a rolled towel behind their back if needed. This position allows you to rest while your baby nurses. It can also be beneficial in the early weeks if you had a cesarean birth or an episiotomy. Clutch or Football Hold In this position you tuck the baby under your arm. Place a pillow behind your back and along the side you are going to nurse on. This will help to support your baby and get their nose at the level of your nipple. • Your forearm will support your baby’s upper back and your hand will hold their head. • Your baby’s body and feet are tucked underneath your arm on the same side that your baby is nursing, so that their legs are behind you. • With this position you can use the other hand to help better position your baby’s mouth on your breast. Pillows can be used to bring your baby to the right level. • Your baby’s body should be in a straight line with their head. Support your baby’s shoulders, neck and head with the palm of your hand.

Side-Lying Hold

Clutch/Football Hold

Readiness is important. Before you start breastfeeding, there are “3 C’s” you should review with yourself each and every time.




Holding your baby skin-to-skin is very helpful to calm your baby in the early days after birth.

Sit in a comfortable chair with pillows for support and elevate your legs with a stool. This will take pressure off your bottom and help you feel more comfortable.

Hold and position your baby close. Have enough pillows to bring the baby up to the level of your breast instead of leaning over. Skin-to-skin contact will help them stay warm and interested in breastfeeding. Proper positioning and latch-on are the keys to successful breastfeeding.

If you have any concerns about how your baby is doing, call your lactation consultant or healthcare provider.


Latch-On Correct Latch

Getting the baby to latch-on correctly is one of the most important steps in successful breastfeeding. Your baby must open their mouth wide enough to get a good amount of areolar tissue into their mouth. If your baby latches on to just the nipple, your nipple will become sore and your baby will get a limited supply of milk. It is the proper compression of the areolar tissue from the baby’s suck, along with the motion of their tongue, that allows the milk to be drawn out through the nipple. Guidelines for proper latch: • Before feeding, wash your hands, find a comfortable place and choose a feeding position. • Skin-to-skin contact can be used before feeding or during a feeding session if your baby isn’t ready to latch on. • Gently massage each breast and hand express until milk comes out. • Line up baby’s chest with your chest and their nose with your nipple. • Support your breast and gently lift it. Make sure your fingers are away from the areolar tissue. • Stroke your baby’s upper lip lightly with your nipple in a downward motion, pausing on baby’s lower lip, to help baby’s mouth to open wide. • Be patient until your baby opens their mouth wide. Let them take the lead. • Baby’s head should be slightly tilted back. • Aim your nipple toward the roof of their mouth. • Their chin should come to your breast first. • When your baby opens wide, quickly and gently pull them toward your breast. • Their mouth should cover the nipple and more of the lower portion of the areola. This is called an asymmetrical or “off-centered” latch. • Good latch-on is a learned response. Be patient with yourself and your baby. Signs of a good latch: • All of the nipple and as much of the areola as possible is in baby’s mouth. • Lips are “flanged” or turned out. • Tongue is over lower gum. • Baby stays on breast. • There is no biting or pinching pain. • Watch for signs of swallowing (long jaw motions). Taking Baby Off the Breast To take your baby off your breast, slide your finger between the corner of the baby’s mouth and your breast to break the suction. Do not pull the baby off your breast. This may traumatize your nipples and make them sore.

Align baby’s nose with your nipple.

Support breast.

Wait for baby to open their mouth wide. Lower lip is further from nipple.

Good positioning makes a good latch possible.

Break suction.


Burping You might try to burp your baby after the feeding. Not all babies will burp within the first few days after birth. Usually the pressure on the baby’s belly is enough to bring up the air. Pat the baby’s back gently or stroke the back with an upward motion. Sometimes babies will not burp. If they did not get a lot of air in the stomach during the feeding, they probably won't. Effective ways of burping: • Over the shoulder. • Lying belly down across your lap. • Sitting in your lap and with chin supported.

How Do I Know if My Baby is Getting Enough to Eat? A common concern is whether your baby is getting enough to eat. There are many clues to indicate that everything is going well. For example, the number of feedings your baby has each day is important. Also, remember that your baby's intake of breast milk is usually reflected by the output of wet and dirty diapers. Positive Signs • Baby feeds well at least 8 or more times in a 24 hour period. • Breast feel softer and less full after feeding.

• You have very little to no pain after the first few sucks. • Your baby is having enough wet and dirty diapers. Baby’s pass meconium for the first 1 to 2 days after birth. Meconium is the sticky black substance that the baby passes from their bowels. The stool changes to a greenish color and then to a mustard yellow color that is runny and seedy in texture. The yellow stool is a good sign your milk supply has increased. After about day 4, babies will pass 3 to 4 stools per day and often pass a little stool after each feeding. If your baby does not have yellow stools by day 4 to 5, contact your lactation consultant or healthcare provider.

Once breastfeeding is established, the best way to ensure a good milk supply is by allowing your baby to determine the frequency and duration of breastfeeding sessions.


Baby is Satisfied

Signs of being full: • Sucking less vigorously, rapid nonnutritive sucking. • Becomes sleepy and relaxes body. • Opens fists. • Baby satisfied – falls away from the breast at the end of feeding. • It is important to listen for nutritive sucking. –– First 3 days may be difficult to hear swallowing. If heard, it sounds like a soft “Ca-Ca” or a soft expiration. –– After larger volume milk arrives, you will hear definite suck-to-swallow ratio changes.

Take cues from your baby; they will let you know!

Weight Gain Nearly all babies lose weight after birth. It is common for them to lose about 7% of their birth weight. As your milk increases they will begin gaining weight at about 4 to 7 ounces per week. Your baby should be back to birth weight by 10 days to 2 weeks. A follow-up appointment for a weight check within the first week of birth is recommended. Having your baby’s weight checked with a lactation consultant or your healthcare provider can provide you reassurance or identify challenges. Breastfeeding Tips Following these steps will help to ensure proper milk removal completely and regularly, increase milk production, reduce breast engorgement and nipple tenderness, and maximize infant weight gain. • Keep your baby interested and awake during feedings. • Offer both breasts each feeding; this helps stimulate milk production. • If your baby chooses to take only 1 breast at a feeding, you may need to express a little from the other side. • Alternate which breast you begin with at each feeding. This will help with proper milk removal of the breasts.

Nursing on baby’s cue stimulates your breasts to produce plenty of milk.


Newborn Feeding Patterns

Babies usually start to showmore feeding cues and eat more often on day 2. Your baby may go through a“marathon” nursing phase, which means they may feed many times close together – this is normal. Keep your baby with you and allow them to feed as often as desired. When your baby falls asleep, you may have a little break if you continue to hold and cuddle them. If you put your baby down, they may wake up and nurse again, not because they are hungry, but because this is comforting. chance to breastfeed at least 8 times today. Gently rub your baby’s legs, feet and back, if needed, to keep them awake and feeding. Babies are resting from birth, so they eat less often in the first 24 hours. Supervised skin-to-skin contact is important! Babies are usually awake and alert for 1 to 2 hours after birth. Then, they often sleep for many hours. Watch for feeding cues, and offer the Babies usually want to “cluster feed”on day 3. Keep your baby skin-to-skin so that they can breastfeed easily. Watch for feeding cues. Feeding by cue means your baby removes milk more often so you make more milk. Your baby may continue with the cluster feedings, then start to ease off as your milk supply increases. Your milk supply will increase and your baby will be eating more at each feeding. You should hear swallowing and even gulping by this time. You may notice your baby becomes satisfied and drifts off to sleep after feeding. It is normal if your baby sleeps more during the day and is awake more at night. Your baby will be eating at least 8 times in 24 hours and may even eat as often as 10 to 12 times in 24 hours. They will start to gain weight. Your baby will also be having more wet and dirty diapers.

Day 1: First 24 Hours Birthday Nap

• At least 1 wet diaper • At least 1 dirty diaper • Black stool (meconium)

Day 2: 24 to 48 Hours Learning Day

• At least 2 wet diapers • At least 2 dirty diapers • Black or dark green stool

Day 3: 48 to 72 Hours All Day Buffet

• At least 3 wet diapers • At least 3 dirty diapers • Brown, green or yellow stool

Day 4 and 5: 96 to 120 Hours Night Owl

• At least 4 wet diapers on day 4 and 5 wet diapers on day 5 • At least 4 dirty diapers • Yellow, loose and seedy stool


Helpful Tips at Home Once you get home from the hospital, find a quiet spot that will allow you and your baby to relax. Keep the lights low and surround yourself with soft, soothing music. Nurse your baby at the first sign they are interested in feeding (see page 12 for feeding cues). Frequent feedings are important to help your baby become skillful at latching on and sucking properly. This frequency also allows for a milk supply that matches your baby’s needs. Emotional support plays an important role in successful breastfeeding. First Few Days at Home • Rest as much as you can – sleep when your baby sleeps. • Limit visitors. • Accept help from your partner, friends or family to cook meals, clean the house or care for your other children. • Make an effort to eat a balanced diet. • Drink to satisfy your thirst. • Be sure you are comfortable and relaxed before you start to nurse your baby. • Find a person who is knowledgeable about breastfeeding to talk with when concerns arise. • Have the number for a lactation consultant before you are discharged from the hospital. A lactation consultant can be an invaluable source of comfort and support. Supporting Breastfeeding As a new parent, you may think that your role is not important since your partner is breastfeeding. The truth of the matter is that the father or partner is one of the most important reasons for their success in breastfeeding. Supporting the choice to breastfeed allows them to relax and enjoy this special time without feeling stressed or pressured. Protect them from criticism from family or friends especially in the early weeks. One way you can help out is by taking turns getting up in the middle of the night. You can change the baby’s diaper and get them ready for feeding. It is amazing how much more rest you can get by sharing roles and responsibilities with your partner. There is a lot of attention directed toward the baby at first. This attention, along with the extreme closeness of a nursing parent and baby, may contribute to feelings of isolation or jealousy for you. This is normal for some, but be patient with yourself and your partner. Talk about your feelings. Parenting takes patience, so communicating with each other about how to manage these new responsibilities will make it easier for both of you. Chances are that your partner is feeling every one of those same fears. Communication with one another is so important in easing fears and negative feelings and makes this time special.

“Watch your baby and not the clock” is advice to live by the first days at home.

Partners, during this precious time give your baby your full attention. They will recognize your voice so talk to them!

Begin a “day out” group where you can take turns watching each other’s babies. Take the time to shop, take a bath, nap or just take a “time out” for yourself.


Breastfeeding Challenges

Cluster Feeding Cluster feeding is when your baby feeds close together at certain times of the day. It usually happens in the evening, but all babies are different. Cluster feeding is very common in newborns. Because all of these feedings may work your body overtime, here are some tips to remember: • You are doing nothing wrong – this is normal. • Make sure you are eating and drinking. • Make yourself a nest for the day and make sleep a priority. • Talk to other parents. Get the support you need. • Ask for help when you need it. • Let your baby breastfeed whenever they want. • Do not supplement your baby with formula. It may decrease your milk supply. Babies who are fed formula still have fussy periods. • Let your baby instinctively breastfeed and know that the fussy period is just a normal stage in your child’s life.

Sleepy Baby Your baby may have a sleepy week or two and you may be challenged to keep your baby interested in feeding. In the early, sleepy days, youmay need to: • Be very attentive to feeding cues the first few weeks after birth. • Undress your baby down to their diaper. • Put your baby skin-to-skin to encourage frequent breastfeeding. • Rub the bottoms of their feet or back to keep them awake. • Talk to your baby while you are nursing. This also may help to keep them interested in finishing the feeding. • Massage and compress your breast during the feeding to increase milk flow. This will gently “remind” your baby to continue sucking. • Wake your baby in order for them to receive enough feedings.

Babies need 8 or more feedings in a 24-hour period.

Growth Spurts You may find there are days that your baby wants to breastfeed more than usual, or cluster feed. Many new parents may worry that something is wrong, but this is a common occurrence with most breastfed babies. This need to breastfeed more often generally lasts a few days to a week. Please know that your baby will return to a less frequent feeding pattern. The common reason for your baby’s need to breastfeed more is “ growth spurts ” and is your baby’s way of increasing your milk supply so that they can grow. Although these days may be more demanding for you, trust what your baby is telling you about their need to breastfeed more frequently and follow your baby’s feeding cues. As long as you do not hold back your baby’s need to breastfeed, your milk supply should be sufficient.


Sore Nipples Some people experience nipple tenderness in the early days of breastfeeding. This is considered to be a “normal type of nipple soreness”which peaks around day 4 to 5 postpartum and is usually better by day 7. Nipple soreness that continues past day 7 or includes open sores, blisters or bruising is not normal and is often due to a poor latch and positioning. Correcting the latch and treating the nipples is important in order to avoid further complications. Getting to the root of the problem will guide the solution. If you cannot identify the problem, call your lactation consultant or healthcare provider. Do not let the problem get worse.

If breastfeeding is painful, figuring out what is causing the pain is a good first step. Knowing the cause will help you learn how to correct the problem and relieve soreness.

How to help sore nipples: • Gently massage breast to stimulate the let-down reflex before putting your baby to breast. • Check your nursing position and baby’s latch. • Touch your baby’s top lip with the tip of your nipple. When your baby’s mouth opens wide, pull your baby in quickly and keep close for the rest of the feeding. Your baby’s nose and chin should be touching your breast. • Begin nursing your baby on the side that is least sore first. • Use relaxation techniques and slow breathing when your baby first begins sucking and for as long as it is helpful. • Encourage your baby to stay awake and to continue productively sucking. Listen for swallowing sounds. • Always break suction with your finger before removing your baby from your breast. • Alternate nursing positions (sitting, lying down and football hold) if you find this helpful. • Do not let your baby stay latched on your breast to sleep when finished with a feeding. You can continue to keep your baby snuggled skin-to-skin, though. • Rub any residual milk over your nipples and let them air dry. Keep your nipples uncovered for as long as you can to let your nipples fully dry. Apply ointment only if recommended by your lactation consultant. Some nipple ointments are more helpful than others. • Warm washcloths can help with comfort. • Hydrogel pads can help soothe the pain. • Call your healthcare provider or lactation consultant if soreness does not improve, or if you have cracked or bleeding nipples.

Pain Rating Scale










worst imaginable pain 10


no pain

Normal breastfeeding discomfort is a 3 or less on the pain scale. If your pain level is higher than this after trying the help measures above, call your healthcare provider or lactation consultant.


Engorgement Your breasts may become engorged (heavier and swollen) 3 to 4 days after childbirth. Engorgement is caused by increased blood flow to the breasts, swelling of the surrounding tissue, and the increase of milk. The breasts will be swollen and uncomfortable for some people, and some may feel a throbbing sensation and discomfort as the milk begins to flow. Some people will feel only a little bit full. As with labor, everyone is different in their experiences. Breast swelling usually goes down within 1 to 2 days. Preventing and treating engorgement: • Breastfeed often and make sure your baby has a good latch. • Avoid the early use of pacifiers, bottles and formula supplementation. • Hand express or pump out milk to soften the areola and nipple. It is Reverse Pressure Softening Reverse pressure softening is a technique that may be useful for engorgement. It is a way to soften the area around the nipple. Doing reverse pressure softening helps the milk to come and make the nipple easier for the baby to latch on. To do reverse pressure softening: • Place your fingers on each side of the nipple. • Push back towards your chest. Hold for about a minute. • Move your fingers around the nipple and press back and hold. • Continue if there are still firm areas. • May be uncomfortable but shouldn’t hurt. sometimes hard for the baby to latch on if the breast is too hard. • Use gentle massage during the feeding to help the milk flow. • Apply cold compresses to the breasts after a feeding. Use a bag of frozen peas or corn for 15 to 20 minutes. This triggers blood vessels to constrict, helps with swelling and draining, and soothes any discomfort. Do not apply frozen bags directly on the skin. • Make sure your bra does not become too tight as this can decrease your milk supply and block milk ducts. • Use warm compresses 3 to 4 minutes before feeding to relax and encourage let-down.

Talk to your clinician or lactation consultant if engorgement is not improved after 24 hours of trying these suggestions.

Reverse Pressure Softening


Blocked Ducts If the milk flow gets clogged, you can get a plugged milk duct. These can feel like pea-sized lumps or an area of engorgement in your breast. They are often sore to the touch, like a bruise. The area may also be warm to the touch. Causes of blocked ducts: • Engorgement from oversupply, limiting feeding time, latching problems. • Infrequent or skipped feedings. • Pressure on a duct from a tight or underwire bra or thumb/finger pressure. • Stress or fatigue. • Breast surgery.

Supportive measures for blocked ducts: • Warm shower or warm pack to affected area. • Frequent feedings.

• Gently massage the affected area toward the nipple while nursing. • Feed your baby on the affected breast first at each feeding session until the plugged duct is better. • Alternate feeding positions if needed. • Hand express or gently pump after feedings.

• Apply a cold pack if there is discomfort after feeding. • Drink plenty of fluids and get adequate nutrition. • REST. • Take anti-inflamatory medications (eg. ibuprofen) Mastitis

If a blocked duct continues, it can become swollen and lead to mastitis . A breast infection can also occur if the nipples are cracked allowing an entry point for infection or if there is already a nipple infection. If an infection occurs, it is the tissue surrounding the blockage, not the breast milk that is infected. Use the supportive measures noted under blocked ducts. In addition, seek treatment from your healthcare provider if you experience any of the following: • Fever over 100.4˚F. • Chills, body aches, or flu-like symptoms. • Mastitis in both breasts. • Breast pain or burning while feeding or all of the time. • Red streaks on the breast. • Baby is less than 2 weeks old. • You have had a recent hospital stay. If you have an infection and your healthcare provider prescribes an antibiotic: • Take it as directed until gone. • If symptoms are not better in 2 to 3 days get re-evaluated.

If the baby refuses to eat or you have to skip a feeding, pump or manually express your milk.


Breast Surgery If you have had breast or nipple surgery you can still breastfeed your baby. Colostrum (the first milk) is hormonally produced and available when your baby is born. This may be all of the milk you produce, or you may produce an abundant supply. Most people fall somewhere in between.

The type of surgery you had will determine how your milk supply may be affected. The location, length and depth of the incision, and if it involved removing the nipple and areola, can impact your milk supply to different degrees. Since milk production, after the initial colostrum, is triggered by nipple and areola stimulation, damage to the nerves, milk ducts, and breast tissue may limit the amount you produce. The more feeling you have in your nipples, the higher chance you have of producing a full milk supply. Make sure your healthcare providers are aware of your surgical history so they know how to address any breastfeeding questions as they apply to you.

Nursing on the Go Although you are not doing anything wrong, you may feel a little uncomfortable about breastfeeding in public. You are feeding your baby and that is normal. Most states have gone as far as implementing laws that protect you as you breastfeed in public. Have confidence in yourself and your decision to breastfeed your baby and the fact that you have fewer supplies to pack, into your diaper bag.

Helpful tips: • Practice at home if you feel uneasy about going out. Have a friend or family member help you or use a mirror to see how you are doing. • Choose clothing that allows easy access to your breast: nursing bras that unfasten easily, nursing tank tops, or loose shirts that you can pull up from the waist. • You can use a special cover, scarf, shawl or light blanket. Be sure to observe your baby breastfeeding and be aware of anything covering their face. • A blanket or cover can sometimes draw more attention to breastfeeding. • Front infant carriers often allow easy breastfeeding. • Use breastfeeding lounges, dressing rooms, or other quiet areas when in public. • Find a booth or choose a seat facing away from the crowd in a restaurant. • Feed your baby as you start to notice cues, this will allow you time to find a comfortable place and position to breastfeed.


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