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Lactation Essentials

Whether you call it breastfeeding, chestfeeding, nursing or bodyfeeding, the team at Premier Pediatrics wants to give you the best possible support and information to help you meet your goals. That’s why we’ve partnered with Lactation Counselor and Postpartum Doula Meema Spadola to assemble this Lactation Essentials page.

For many parents, a little information about what to expect can be empowering, so learning the basics before your baby arrives is a great way to get off to a good start and build confidence.

LEARNING THE BASICS

We suggest you take a look at the following resources now and make a mental note of where they are so you can revisit them from time to time once your baby has arrived.

This very short (2-page) KellyMom.com article, Breastfeeding Your Newborn: What to Expect in the Early Weeks, is a great way to understand normal newborn feeding patterns and how to tell that your baby is getting enough milk. (Instead of randomly Googling questions about nursing, KellyMom.com is a good evidence-based site to bookmark!)

This 30-second video demonstrates a good latch, audible swallows, and a pause to breathe that you should see and hear when your baby is nursing efficiently after your milk has increased or “come in” around day 3-5.

This graphic illustrates the difference between how we often imagine that babies nurse versus how they actually tend to nurse (cluster feeds, feeds of varying sizes/lengths, etc.). This is often a stumbling block for parents who incorrectly interpret their baby’s normal feeding patterns as a sign that they don’t have enough milk.

 

ON YOUR BABY’S BIRTHDAY

Your baby has been born and now our story begins. After your baby has declared their entrance to the world with that exhilarating initial cry, they should be placed “skin to skin” on your chest. At this moment, a baby’s instincts kick in and they slowly make their way to the breast, latch, and nurse. This is called the “breast crawl.”

Being skin to skin helps to regulate a baby’s body temperature, respiration, heart rate, and blood sugar. It also helps to keep a baby calm and lets you respond more quickly to feeding cues.  Beyond this initial feed, holding your baby skin to skin in the early days and weeks is a great way to start nursing sessions and calm your baby.

The first hour of life is often called the “golden hour.” Your baby will be awake, searching for the breast, and suckling. It’s an incredible moment for parents to share with their baby. After the “golden hour,” babies need their sleep. They often sleep for 5-6 hours. There is no need to wake to feed, so get some rest yourselves!  If you give birth by cesarean, having your baby skin to skin and the breast crawl may be delayed until you are in recovery. If you are having a planned cesarean birth, you can discuss  a “family-centered” or “gentle” cesarean with your provider, which may make it possible to hold your baby skin to skin.

Once your baby wakes from this initial long sleep, expect to feed your baby 8-12 times (or more) per 24 hour period for the first 6 weeks or so. A feed is at least 10 minutes of active sucking and swallowing, but it’s best not to limit your baby if they are actively sucking. (Watch this short video to see what that looks and sounds like.)

In order to make sure your baby gets enough milk and that you establish a good supply, feed your baby on cue. Having your baby sleep nearby per the American Academy of Pediatrics means you’ll catch those cues before your baby gets frustrated and cries.

  • Early cues: stirring, mouth opening, turning head, seeking/rooting

  • Middle cues; stretching, increasing physical movement, hand to mouth

  • Late cues: crying, agitated, turning red

  • If your baby is distressed, try to calm your baby by holding them upright on your chest skin to skin, then feed!

Be aware that when your baby is swaddled, those cues can be suppressed, so if your baby isn’t waking on their own, you might want to unswaddle them to see if they are ready to nurse. Try to be patient with your baby and yourself in these first days as you learn a new skill and wait for your volume of milk to increase. Keep in mind that this is a phase and easier days are around the corner.

If you and your baby are separated after the birth, no need to worry. Start doing breast massage and hand expression to stimulate your supply and get small amounts of colostrum to feed your baby with a syringe, spoon or medicine cup that you can request from the hospital staff. Use a free, hospital-provided breast pump every 2-3 hours for longer separation.

 

THE FIRST TWO DAYS OF NURSING

Keep in mind: On Day 1, your baby would rather sleep than eat. On Day 2, your baby would rather eat than sleep!

In the first few days of life, your baby is drinking colostrum. Your body makes colostrum during your pregnancy, so you already have the perfect newborn food available from the beginning! Colostrum lines and protects your baby’s gut, supports their immune system and helps prevent jaundice. It’s also highly concentrated and nutrient-dense, so your baby only needs small amounts. On day 1, a full feed is approximately 2-10 ml or from less than ½ to 2 tsp; by day 2 it ranges from 5-15 ml, 1-3 tsp.

In the beginning, it is very normal for newborns to be sleepy when they nurse. You can do “compressions,” gently squeezing your breast to increase the flow of milk and encourage your baby to keep sucking and swallowing.

If your baby does not latch or swallow when at the breast or falls asleep quickly, then you can hand express colostrum into a teaspoon or medicine cup and use those or a syringe to feed this expressed colostrum to your baby. This is more efficient than pumping and offering a bottle in these first days of life. Sometimes offering a little colostrum to a sleepy baby can give them energy to nurse, so you can try that at the beginning of a feed too.

Here are two videos that demonstrate hand expression: Hand Expression of Breastmilk with Dr. Jane Morton (good for the first few days of life) and The Basics of Massage and Hand Expression with Maya Bolman (especially good for engorgement and after your milk supply has increased).

To be sure that your baby is getting enough milk, look for 1 wet and 1 dirty diaper on day 1 and on day 2, 2 of each.

 

NURSING DURING DAYS 3-5

Between day 3-5 you will transition from colostrum to mature milk and the volume will increase. A full feed on day 3 is about 15-30 ml, ½ to 1 ounce and day 4 is about 30-60 ml (1-2 ounces). So you can see that the amounts your baby takes are increasing rapidly! You may experience engorgement (your breasts will feel heavy, hard and warm and it may be harder for babies to latch easily, because as your breasts expand with milk and excess fluid, the nipple becomes less pronounced and the areola is firmer). To avoid and relieve engorgement: nurse on cue; do the reverse pressure softening technique to make it easier for your baby to latch; use warm compresses for 2-4 minutes before and cool compresses after nursing; and hand express milk. You can also use plain green cabbage leaves to relieve engorgement. (Peel off a couple leaves from a head of cabbage, wash them, scrunch them in your hands or crush with a rolling pin and then wear inside your bra for about 20 minutes. Stop doing this after about a day since using cabbage leaves long term can reduce your milk supply!) If you were on an IV during labor (whether for a vaginal or cesarean birth), you will likely experience more pronounced engorgement due to the excess IV fluids in your body. In this case, it’s best to avoid using an electric or manual pump for more than 3-5 minutes, because it can actually draw some of that excess IV fluid into the areola and nipple area, making it even harder for your baby to latch. To help move that fluid out of your breasts, try doing “breast gymnastics” per Maya Bolman. This extreme engorgement should resolve in about 24-48 hours.

When you’re nursing your baby, aim to let your baby “finish” the first breast, then burp them and offer the other side. When your baby is done on one side, they might unlatch on their own or just suck way more slowly, even when you do compressions. You can also check to see if they’re a bit more relaxed in their brow, shoulders, arms and hands (e.g., are their hands still balled up into fists or open?). Your breast should also feel softer after they are done on that side. Remember that this isn’t an exact science and it’s okay if you don’t always read the signs just right! If your baby won’t take the second breast or stays on for only a very short time, that’s fine– just start with that side the next time.

Until your baby is back at birth weight, wake them to feed if it’s been 3 hours since the beginning of last feed during the day or 4 hours during the night. (You might try leaving them unswaddled during the day and only swaddling at night since the swaddle can suppress their feeding cues.) Again, ideally you will be feeding your baby by following their cues instead of watching the clock. Remember that it is normal for newborn babies to feed in an irregular pattern, to “cluster feed” (nurse several times in a row), and to vary the length of time that they nurse each time and at each breast! None of these things on its own is reason for concern as long as your baby is gaining weight appropriately and making enough wet and dirty diapers, as noted below.

Babies usually lose 5-7% of their birth weight by day 3. Losing 10% or above is a sign that you should seek lactation support. Be aware that if you were on an IV during labor, your baby’s birth weight is likely artificially inflated and you may see a larger drop in weight.

In addition to having your baby weighed at our office, you can assure yourself that your baby is getting enough milk by counting your baby’s wet and dirty diapers. To know that your baby is getting enough milk between day 3-5, look for one wet and one dirty diaper for each day of life, so 3 wet and 3 dirty on day 3 and so on. After day 4, your baby should be making yellow poops that are the size of a quarter or larger. They will be loose (soft and runny) and may be seedy or curdy. Urine should be totally clear after day 3.

 

IF YOUR BABY ISN’T GAINING ENOUGH WEIGHT

If your baby has lost over 10% of their birth weight or isn’t gaining quickly enough, we will ask you to supplement your baby’s nursing sessions with expressed breastmilk and we will provide guidance about how much to offer. If you aren’t able to express enough milk at first (either by hand or with a pump), then you can use formula to make up the difference. You can use paced bottle feeding to help your baby go back and forth easily between breast and bottle.

When you are pumping, you will get more milk if you begin each session by doing some massage and hand expression, then wearing a pumping bra (that holds the pump parts against your breasts) and doing compressions (gentle squeezes) during pumping. Try pumping for 10-15 minutes and know that it might take a while to get used to pumping, so don’t worry if at first you aren’t expressing much milk.

When we are asking you to supplement, we will have you come back to the office so we can check your baby’s weight and discuss how and when to end the supplemental feeds. It’s also important to make sure that we have gotten to the root of the problem, so we may suggest that you see a lactation professional for additional support.

 

NURSING WEEK 1 TO 2

Babies should be back to their birth weight by 1-2 weeks, then should gain about 1 oz/day up until 4 months. By one week you’ll want to see at least 4 yellow poops every day (until around 4-6 weeks when those might decrease) and at least 5-6 wet diapers (the equivalent of 3 Tb/ 45 ml of liquid) every day. By one week, your baby will take around 45-60ml (or 1.5-2 ounces) at each feed. And by day 10, that increases to about 60-81 ml (or 2-3 ounces).

Again, once your baby is back at their birth weight and you’re seeing 5-6+ wet and 4+ dirty diapers per 24 hours, you can stop waking your baby to feed at night. It’s up to you if you choose to continue waking your baby every few hours during the day. Babies are usually much sleepier during the day and more wakeful at night.

Around two weeks of age, you’ll likely notice that your baby will be more wakeful and will likely develop a fussy period in the evening where they “cluster feed,” nursing a number of times in a row. This is not a sign that you don’t have enough milk or that something is going wrong, but rather it’s a normal part of newborn development and it will pass! (Again, you can monitor your baby’s diaper output to be sure that they are getting enough milk.)

 

BUILDING AND MAINTAINING A SUPPLY

The best way to build and maintain your supply of milk is to follow your baby’s feeding cues. This will work way better than any lactation cookies or teas! (Of course it’s good to eat nourishing food that you love, so if you adore lactation cookies, go for it!) The bottom line is that more milk out means more milk made. Here are some things to remember:

  • Your supply will increase rapidly over the first 4 weeks and then begin to level off

  • If possible, wait to pump until about 3 weeks so that you and your baby can get really comfortable with nursing

  • Avoid pacifiers until nursing is “well established,” per the AAP. (A good choice is the Soothie brand pacifier.)

 

HOW TO MAKE NURSING COMFORTABLE

Pain while nursing is a sign that your baby’s latch (the way they are attached at the breast) isn’t right. And, in fact, when you’re in pain, your milk won’t flow as quickly, so a poor latch isn’t good for you or your baby. Put your finger in the corner of your baby’s mouth to break the seal, take your baby off and try again. Some discomfort or soreness is normal and in the beginning, the first 20 seconds after your baby latches may be uncomfortable as they suck vigorously to get your milk flowing.

So, how do you get a good latch and avoid pain?

  • Start with a calm and unswaddled baby

  • You should be in a comfortable position

  • Let gravity help you by leaning back with baby against your body instead of lifting baby up to your body

  • Hold baby close, with baby’s chest/belly touching your body

  • Check that baby’s ear, shoulder and hip are in line, so they’re comfortable and it’s easier to swallow

  • Focus on an asymmetrical latch, bring baby’s chin in first

  • Aim baby’s nose to your nipple

  • When possible, let the baby latch; don’t chase the baby with your nipple!

  • If you need to support or shape your breast, think about lining up that “sandwich” in the same direction as your baby’s mouth and keep your fingers out of the way of where they are trying to latch

  • Gently support your baby across their shoulders, don’t push on the back of your baby’s head

If you have sore nipples, try a gentle warm saline rinse for about 1 minute on each side (1 cup of hot water with 1/2 tsp of table salt, mix to dissolve and use when cool enough). See this Kelly Mom page about healing sore nipples for guidance on this & other tips. Consider using hydrogels (like the Soothies brand) for healing nipples. You can also put coconut oil on a disposable nursing pad and wear that inside your bra for extra comfort/protection against any chafing. (You might consider avoiding lanolin if you have broken skin on your nipples, since it can trap bacteria and irritate some people’s skin.) If the skin of nipples is cracked, wash nipples once a day with mild, unscented, non-antibacterial soap.

But remember, the best way to heal is to fix the poor latch! If you still are in pain after trying the tips below, please reach out for help. Premier Pediatrics has an IBCLC (International Board Certified Lactation Consultant) in our Brooklyn and Manhattan offices once a week.

 

HOW PARTNERS CAN SUPPORT

  • Do skin to skin to calm baby before or after a feed

  • Bring water and food

  • Burp baby after feed

  • Do diaper changes

  • Learn how to “babywear” (in a carrier or wrap)

  • Become a super baby soother

  • Provide encouragement

  • When the time is right to start pumping and bottle feeding, learn how to do paced bottle feeding

 

HUMAN MILK STORAGE GUIDELINES FROM CDC

Freshly expressed or pumped milk can be stored:

  • At room temperature (77°F or colder) for up to 4 hours.

  • In the refrigerator for up to 4 days.

  • In the freezer for about 6 months is best; up to 12 months is acceptable.

  • Leftover milk in a bottle which you have fed to your baby should be refrigerated and used within about 2 hours.

Use breast milk within 24 hours of thawing in the refrigerator (this means from the time it is no longer frozen or is completely thawed, not from the time when you took it out of the freezer).

Once breast milk is brought to room temperature or warmed after storing in the refrigerator or freezer, it should be used within 2 hours. Don’t refreeze breast milk once it has been thawed.

ADDITIONAL INFO & RESOURCES

  • Per the AAP, nursing babies should get 400 IU (International Units) of vitamin D per day beginning soon after birth. We recommend D Drops or Carlson’s Vitamin D, which has no added flavors or colors and is a single drop dose per day.

  • Whether you’re nursing, formula feeding or a combo, babies go through growth spurts, during which they want to feed more and may be a bit fussier. Common times for growth spurts are during the first few days at home, around 7-10 days, 2-3 weeks, 4-6 weeks, 3 months, 4 months, 6 months and 9 months (more or less, depending on the individual baby, gestational age, etc.).

  • Infant Risk Center at Texas Tech University Health Sciences Center are the foremost experts on the safety of medications while pregnant or breastfeeding.

  • To learn more about insurance coverage for lactation support, check out this resource from National Women’s Law Center.

  • If you’re having trouble with your insurance company coverage, here’s a short guide written by Medela that might be helpful.