Breastfeeding and Making Milk for Your Baby

Breastfeeding and Making Milk for Your Baby Dear New Parents, Congratulations on the birth of your new baby! There are so many reasons to breastfeed your newborn and we are here to help you along the way. Some reasons you might choose to breastfeed are: • The closeness and bonding with your baby • The best nutrition that only you can provide • The cost savings • It makes nighttime feedings easier • The many health benefits to mother and baby Please keep in mind that feeding your new baby is a learned skill. It may take some patience and practice. You may have additional challenges if your baby was born early or if you have health problems. For some women, breastfeeding can be frustrating in the beginning. The good news is that it gets easier. The staff in the Birth Center has been trained to help you learn to feed your new baby. The Lactation Consultants are available for additional help as well. We have also provided this booklet for you with additional information to help you as you learn to feed your newborn. The following page contains information about resources to help you in your community and online, including our phone number if you get home and find you need additional help. Most of this booklet comes from, “Your Guide to Breastfeeding,” which can be found on the breastfeeding page of the Office on Women’s Health. Because only part of the book is found here, some of the page numbers referenced in this book may not be present. If you would like to view the entire book, please visit their website. The remaining pages of this booklet are from Lactation Education Resources website. Their website is listed on the next page as well. Please call the Lactation Line at 414-805-3995 with any additional questions or problems.

Sincerely, The Froedtert Birth Center Staff and Lactation Consultants Breastfeeding Resources Froedtert Lactation Support Froedtert Lactation Line: 414-805-3995 Froedtert Monthly Breastfeeding Support Group: 414-805-3945 Froedtert Returning to Work and Breastfeeding Class: 414-805-4777 Breastfeeding Support Groups in the Milwaukee Area • La Leche League of Wisconsin https://www.lllofwi.org/find-a-group.html • Miltown Moms www.miltownmoms.com/#!breastfeeding/c19e • African American Breastfeeding Network of Milwaukee aabnetwork.org/ • Local WIC Offices in Wisconsin https://www.dhs.wisconsin.gov/wic/local-projects.htm • Wisconsin Directory of Breastfeeding Support • www.wibreastfeeding.com/wp-content/.../BFResourcedirectory2014.doc Online Breastfeeding Resources General Breastfeeding Information: 1. Your Guide to Breastfeeding:  The Office on omen’sW Health 48 page book about breastfeeding. 2. Lactation Education Resources: Handouts for Parents  Many topics including: Engorgement, Mastitis, Plugged Ducts, Latching, Overactive Letdown, and many more. 3. Kelly Mom: kellymom.com 4. La Leche League International: lalecheleague.org 5. Dr Jack Newman: breastfeedingonline.com/newman.shtml 6. Global Health Media Project: Our Videos - Breastfeeding  18 breastfeeding videos, available in 21 languages – Attaching Your Baby at the Breast and other videos may be viewed on You tube. Information about Latch and Positioning: 7. Natural Breastfeeding: For an Easier Start - Nancy Mohrbacher, IBCLC  Baby-led breastfeeding. 8. Jessica Barton, IBCLC: youtube.com  Series 7 videos showing various breastfeeding positions to improve latch.  Paced Bottle-feeding for the Breastfed Baby.

Page 1 Information about Preterm Delivery and Expressing Milk: 9. Getting Started with Breastfeeding - Jane Morton MD  Breastfeeding videos and information. 10. US San Diego Health: Supporting Premature Infant Nutrition (SPIN)  This series of five videos follows one family with 24-week twins in their journey from skin-to-skin care through learning how to breastfeed as they get ready to go home. 11. Work and Pump: workandpump.com  This website provides information about breastfeeding, pumping, storing milk and going back to work. Special Situations: 12. Low Milk Supply Website: lowmilksupply.org  Low Milk Causes, Oversupply, Supplementation, Increasing Milk Supply. 13. BFAR: bfar.org Breastfeeding After Reduction website. Information about Breastfeeding after Breast and Nipple Surgeries. 14. LactMed  National Institute of Health database, recommended source for information about medications during lactation. 15. Moms Mental Health Initiative http://momsmentalhealthmke.org/  Helps moms with perinatal mood and anxiety disorders in the Greater Milwaukee area get better by leading them to effective treatment.  Online support group. Breastfeeding Books • Breastfeeding Made Simple: Seven Natural Laws for Nursing Mothers. Mohrbacher & Kendall-Tackett. 2010. • Happiest Baby on the Block. Harvey Karp. 2003. • Mothering Multiples: Breastfeeding and Caring for Twins or More! Kerhof-Gromada, K. 2007. • Exclusive Pumping and Milk Supply. Glenn, Amanda. 2004. • Working and Breastfeeding Made Simple. Mohrbacher, Nancy. 2014. • The Nursing Mother's Companion. Huggins, Kathleen. 2010. • The Breastfeeding Guide to Making More Milk. West, D & Marasco. 2009. • The Womanly Art of Breastfeeding. Wiessinger, D; West, D; and Pitman, T. 2010. • Sweet Sleep: Nighttime and Naptime Strategies for the Breastfeeding Family. Wiessinger, West, Smith, & Pitman. 2014.

Page 2 YourYOUR GUIDE Guide TO BREASTFEEDING to Breastfeeding

WHY BREASTFEEDING IS IMPORTANT

BREASTFEEDING PROTECTS BABIES

YOUR FIRST MILK IS LIQUID GOLD. mature milk has just the right amount of This protection is unique and changes Called liquid gold for its deep yellow fat, sugar, water, and protein to help your to meet your baby’s needs. Research color, colostrum is the thick first milk that baby continue to grow. It looks thinner suggests that breastfed babies have lower you make during pregnancy and just after than colostrum, but it has the nutrients risks of 1: birth. This milk is very rich in nutrients and antibodies your baby needs for • Asthma and includes antibodies to protect your healthy growth. • Childhood leukemia baby from infections. Colostrum also • Childhood obesity helps your newborn infant’s digestive FORMULA IS HARDER TO DIGEST. • Ear infections system to grow and function. Your baby For most babies, especially premature • Eczema (atopic dermatitis) gets only a small amount of colostrum at babies, breastmilk substitutes like • Diarrhea and vomiting each feeding because the stomach of a formula are harder to digest than • Lower respiratory infections newborn infant is tiny and can hold only breastmilk. Formula is made from cow’s • Necrotizing enterocolitis, a disease a small amount. (Turn to page 19 to see milk, and it often takes time for babies’ that affects the gastrointestinal tract just how small your newborn’s tummy stomachs to adjust to digesting it. in preterm infants is!) • Sudden infant death syndrome BREASTMILK FIGHTS DISEASE. (SIDS) YOUR MILK CHANGES AS YOUR BABY GROWS. The cells, hormones, and antibodies in • Type 2 diabetes Colostrum changes into mature milk by breastmilk protect babies from illness. the third to fifth day after birth. This

In some situations, formula-feeding can save lives.

Very rarely, babies are born unable to tolerate animal milk of any kind. These babies must have an infant formula that is hypoallergenic, dairy free, or lactose free. A wide selection of specialty baby formulas now on the market include soy formula, hydrolyzed formula, lactose-free formula, and hypoallergenic formula. DID YOU KNOW? Speak with your doctor before you decide to feed your baby anything besides your breastmilk.

Your baby may need formula if you have certain health conditions that won’t allow you to breastfeed and you do not have access to donor breastmilk. To learn more about breastfeeding restrictions in the mother, see page 29. To learn more about donor milk banks, see page 36.

1Stuebe, A. (2009). The Risks of Not Breastfeeding for Mothers and Infants. Obstetrics and Gynecology; 2(4): 222–231. 4 Page 3 Besides giving your baby nourishment and helping to keep your baby from CAN BREASTFEEDING HELP ME becoming sick, breastfeeding may help you lose weight. Many women who breastfed LOSE WEIGHT? their babies said it helped them get back to their pre-pregnancy weight more quickly, but experts are still looking at the effects of breastfeeding on weight loss.

WHY BREASTFEEDING IS RIGHT FOR YOU

Did you know that your baby can smell sterilize. You do not have to buy, measure, BREASTFEEDING KEEPS MOTHER AND BABY CLOSE. you and knows the unique scent of your and mix formula. You won’t need to warm Physical contact is important to breastmilk? This is why your baby will bottles in the middle of the night! When newborns. It helps them feel more turn her head to you when she is hungry. you breastfeed, you can satisfy your secure, warm, and comforted. Mothers Your baby is born with an instinct to baby’s hunger right away. also benefit from this closeness. The suckle at your breasts. skin-to-skin contact boosts your oxytocin NOT BREASTFEEDING COSTS MONEY. levels. Oxytocin is a hormone that helps LIFE CAN BE EASIER WHEN YOU BREASTFEED. Formula and feeding supplies can cost breastmilk flow and can calm the mother. Breastfeeding may seem like it takes a more than $1,500 each year. Breastfed little more effort than formula feeding at babies may also be sick less often, which BREASTFEEDING IS GOOD FOR THE MOTHER’S first. But breastfeeding can make your life can help keep your baby’s health costs HEALTH, TOO. easier once you and your baby settle into lower. Breastfeeding is linked to a lower risk of a good routine. When you breastfeed, Type 2 diabetes, certain types of breast there are no bottles and nipples to cancer, and ovarian cancer in mothers.2

BREASTFEEDING GLOSSARY Nutrients are any food substance that provides energy or helps build tissue.

Antibodies are blood proteins made in response to germs or other foreign substances that enter the body. Antibodies help the body fight illness and disease by attaching to germs and marking them for destruction.

The gastrointestinal system is made up of the stomach and the small and large intestines. It breaks down and absorbs food.

The respiratory system includes the nose, throat, voice box, windpipe, and lungs. Air is breathed in, delivering oxygen. Waste gas is removed from the lungs when you breathe out.

2U.S. Department of Health and Human Services. (2011). The Surgeon General’s Call to Action to Support Breastfeeding. 5 Page 4 BREASTFEEDING MYTHS

Moms-to-be and new moms get a lot of ligaments of your breast tissue, whether MYTH: YOU WON’T BE ABLE TO MAKE ENOUGH MILK. baby advice. Although people usually you breastfeed or not. Age, genetics, and Moms almost always make enough milk mean well, not all of it is based on fact. the number of pregnancies you’ve had to feed their babies. A newborn’s stomach Myths about breastfeeding are common. also play a role. is only the size of a hazelnut. If you eat The fact is that breastfeeding is a healthy healthy, drink water, and nurse often, way to feed your baby. The decision MYTH: IF YOUR BREASTS ARE TOO SMALL, YOU CAN’T your milk supply should be plentiful. to breastfeed is a personal one, and it BREASTFEED. should also be an informed one. Size and shape of breasts do not affect MYTH: BREASTFEEDING SPOILS A CHILD. ability to breastfeed and have nothing After spending nine months growing MYTH: EVERYONE USES FORMULA. to do with how much milk a woman inside you, it’s completely natural for a More women breastfeed than you think. actually makes. This includes women baby to be attached to his or her mother According to the Centers for Disease with large areolas (the area around the and vice versa. Despite what you’ve Control and Prevention, 80 percent of nipple), flat nipples, and even women heard, newborns don’t need to learn women in the United States start out who’ve had breast surgery. (Note: If to fend for themselves at such a young breastfeeding3. Research over the past you’ve had a massive breast reduction, age. In reality, breastfeeding provides a 40 years has proven that mother’s milk milk ducts and glands might have been unique bond with your child that can last is an inexpensive and healthy choice for removed, which means you may make a lifetime. Research shows that breastfed babies. less milk.) children grow up to be confident and self- sufficient when parents meet their needs. MYTH: FORMULA HAS MORE VITAMINS THAN MYTH: IF YOUR BREASTS ARE TOO LARGE OR YOU’RE BREASTMILK. PLUS SIZE, YOU CAN’T BREASTFEED. MYTH: BREASTFEEDING HURTS. In fact, the opposite is true. Formula Women of all sizes can successfully Breastfeeding is not supposed to be a cannot match the nutrients and vitamins breastfeed. So if you’re a larger mom-to- painful experience. In fact, pain is usually in breastmilk. More importantly, be or new mom, you should not let the a red flag that something is wrong. breastmilk has antibodies, which can size of your breasts automatically rule Although a baby’s latch can be strong, only be passed from your body to your it out. If you’re big breasted, it may take it’s not actually biting, not even when the baby. This is what helps protect your some extra patience or some assistance baby is cutting teeth. As with any new baby from getting sick. Breastmilk is from an IBCLC. Plus-size women are skill, there is an adjustment period. See recommended by the American Academy more likely to have C-sections, which page 14 to learn more. of Pediatrics and the World Health means your milk might come in a few Organization. Breastfeeding is a great days later. Depending on the size of Learn more about the benefits of choice to ensure your baby’s nutrition. your breasts, you may need a little more breastfeeding for both mom and baby practice to find a hold that works for you on page 4. MYTH: BREASTFEEDING MAKES YOUR BREASTS SAG. and your baby. But with the right help Actually, it’s pregnancy that stretches the and support, you can do it!

3Centers for Disease Control and Prevention, Breastfeeding Among U.S. Children Born 2002-2012, CDC National Immunization Survey, 2015.

Page 5 HOW YOUR MILK IS MADE

Your breasts make milk in response to The breasts often become fuller and your baby’s suckling. The more your tender during pregnancy. This is a sign baby nurses, the more milk your breasts that the alveoli are getting ready to work. will make. Knowing how your breast Some women do not feel these changes makes milk can help you understand the in their breasts. Other women may sense Lobes breastfeeding process. The breast is an these changes after their baby is born. organ that is made up of several parts: The alveoli make milk in response to the hormone prolactin. Prolactin rises when ALVEOLI CELLS: grape-like clusters of tissue the baby suckles. Another hormone, Areola that make the milk oxytocin, also rises when the baby suckles. This causes small muscles in AREOLA: the dark area around the nipple the breast to contract and move the milk Nipple through the milk ducts. This moving of LOBES: the parts of the breast that make the milk is called the “let-down reflex.” milk; each lobe contains alveoli cells and Milk duct milk ducts The release of prolactin and oxytocin may make a mother feel a strong sense of MILK DUCTS: tubes that carry milk through needing to be with her baby. Alveoli cells the breast to the nipple/areola area

NIPPLE: the protruding point of the breast

The let-down reflex (also called just “let-down” or the milk ejection reflex) happens when your baby begins to nurse. The nerves in your breast send signals that release the milk into your milk ducts. This reflex makes it easier for you to breastfeed your baby. Let-down happens a few seconds to several minutes after you start breastfeeding your baby. It also can happen a few times during a feeding. You may feel a tingle in your breast, or you may feel a little uncomfortable. You also may not feel anything. WHAT IS THE LET-DOWN REFLEX? Let-down can happen at other times, too, such as when you hear your baby cry or when you’re just thinking about your baby. If your milk lets down as more of a gush and it bothers your baby, try expressing some milk by hand before you start breastfeeding.

Many factors affect let-down, including anxiety, pain, embarrassment, stress, cold, excessive caffeine use, smoking, alcohol, and some medicines. Mothers who have had breast surgery may have nerve damage that interferes with let-down.

Page 6 YOUR GUIDE TO BREASTFEEDING

LEARNING TO BREASTFEED

Breastfeeding is a process that takes time The following steps can help you get off • Let your baby stay in your hospital and practice. Keep in mind that you make to a great start breastfeeding: room all day and night so that you milk in response to your baby sucking at • Cuddle with your baby skin-to-skin can breastfeed often. the breast. Luckily, your baby loves being right away after giving birth. • Try to avoid giving your baby any close to you and sucking at your breasts. • Breastfeed as soon as possible after pacifiers or artificial nipples until he All that time spent breastfeeding in your giving birth. or she is skilled at latching onto your baby’s first few days prepares your body • Ask for an IBCLC to help you. breast (usually around 3 to 4 weeks to make lots of milk, whether you go • Ask the hospital staff not to give old). on to breastfeed for three weeks or your baby pacifiers, sugar water, three years. or formula, unless it is medically necessary.

PREPARE FOR BREASTFEEDING BEFORE YOU GIVE BIRTH

To prepare for breastfeeding, the most successful breastfeeding. These places have had. If you have depression or are important thing expectant moms can are called Baby-Friendly Hospitals and taking supplements or medicines, talk do is to have confidence in themselves. Birth Centers. with your doctor about treatments that Committing to breastfeeding starts with can work with breastfeeding. the belief that you can do it! TAKE A BREASTFEEDING CLASS. Pregnant women who learn how to breastfeed are more TELL YOUR DOCTOR THAT YOU WOULD LIKE TO Other steps you can take to prepare for likely to be successful at breastfeeding BREASTFEED AS SOON AS POSSIBLE AFTER DELIVERY. breastfeeding are: than those who do not. Breastfeeding The sucking instinct is very strong within classes offer pregnant women and their the baby’s first hour of life. GET GOOD PRENATAL CARE, which can help you partners the chance to prepare and ask avoid early delivery. Babies born too early questions before the baby’s arrival. TALK TO FRIENDS WHO HAVE BREASTFED, or have more problems with breastfeeding. consider joining a breastfeeding support ASK YOUR DOCTOR TO RECOMMEND A LACTATION group. TELL YOUR DOCTOR ABOUT YOUR PLANS TO CONSULTANT. You can establish a BREASTFEED, and ask whether the place relationship with a lactation consultant GET THE ITEMS YOU WILL NEED FOR BREASTFEEDING, where you plan to deliver your baby has before the baby comes so that you will such as nursing bras, covers, and nursing the staff and setup to support successful have support ready after the baby is born. pillows. You may want to pack these in breastfeeding. Some hospitals and your bag to have at the hospital when you birth centers have taken special steps to TALK TO YOUR DOCTOR ABOUT YOUR HEALTH. Discuss deliver your baby. create the best possible environment for any breast surgery or injury you may

Page 7 Early and often! Newborns usually need to nurse at least eight to 12 times every 24 hours. This also helps make sure you will make plenty of milk. HOW OFTEN SHOULD I BREASTFEED? Healthy babies develop their own feeding patterns. Follow your baby’s cues for when he or she is ready to eat.

FOLLOW YOUR BABY’S LEAD

Getting your baby to “latch” on properly Keep in mind that there is no one way to your chest. If your baby is hungry, he will takes some practice and can be a source start breastfeeding. As long as the baby is bob his head against you, try to make eye of frustration for you and your baby. One latched on well, how you get there is up contact, and squirm around. approach to learning to breastfeed is a to you. more relaxed, baby-led latch. This laid- SUPPORT YOUR BABY, BUT DON’T FORCE THE LATCH. back, more natural breastfeeding style CREATE A CALM ENVIRONMENT FIRST. Lie back Support his head and shoulders as allows your baby to lead and follow his or on pillows or another comfortable area. he searches for your breast. Avoid the her instincts to suck. Make sure you are relaxed and calm. temptation to help him latch on.

The following steps can help your HOLD YOUR BABY SKIN-TO-SKIN. Hold your ALLOW YOUR BREAST TO HANG NATURALLY. When newborn latch onto the breast to start baby, wearing only a diaper, against your baby’s chin hits your breast, the firm sucking when he or she is ready. Letting your bare chest. Hold the baby upright pressure makes her open her mouth wide your baby begin the process of searching between your breasts and just enjoy your and reach up and over the nipple. As for the breast may take some of the baby for a while with no thoughts of she presses her chin into the breast and pressure off of you and keeps the baby breastfeeding. opens her mouth, she should get a deep calm and relaxed. latch. Keep in mind that your baby can LET YOUR BABY LEAD. If your baby is not breathe at the breast. The nostrils flare to hungry, he will stay curled up against allow air in.

There is no set time for feedings. They may be 15 to 20 minutes per breast. They may be shorter or longer. Your baby will let you know HOW LONG SHOULD when he or she is finished feeding. FEEDINGS BE? If you worry that your baby is not getting enough milk, talk to your baby’s doctor. See page 55 for a feeding tracker if you would like to write down how often your baby wants to eat.

Page 8 YOUR GUIDE TO BREASTFEEDING

GETTING YOUR BABY TO LATCH

If your baby is still having problems latching on, try these tips:

Tickle the baby’s lips to encourage him Pull your baby close so that the chin and Watch the lower lip and aim it as far from or her to open wide. lower jaw moves into your breast first. base of nipple as possible, so the baby takes a large mouthful of breast.

When my son was born four years ago, we had a very difficult time breastfeeding because he wasn’t latching correctly. He seemed almost lazy and disinterested in eating. In the first two weeks, he lost quite a bit of weight and appeared gaunt and fussy. Naturally, I was nearly frantic with worry. Luckily, I connected with SOME BABIES LATCH ON RIGHT an amazing lactation consultant. She put me on a rigorous, week-long regimen, AWAY, AND FOR SOME IT TAKES which consisted of nursing, then bottle feeding breastmilk, then pumping every MORE TIME. three hours. I was completely dedicated to the regimen, and when I met with her a week later, she was stunned by the results. My son had gained an entire pound, and she said he had developed a perfect latch. She called us the miracle mom and miracle baby! I was so proud of us. My determination paid off, and I enjoyed breastfeeding for seven months. — Jill, Bridgewater, Massachusetts

Page 9 Information for breastfeeding families Positioning & Latch-on : Baby-led Latching

The way you hold your baby and how he latches Positioning your baby on to the breast are the keys to comfortable Position the baby between your breasts and feeding for you and full feedings for your baby. allow your baby to wake skin-to-skin. Holding Correct positioning and latch-on can prevent your newborn skin-to-skin is one of the best many of the common problems mothers ways to make breastfeeding easy! encounter when starting to breastfeed. Be Patient Baby-led latching is good for the first feeding and Your baby will gradually realize where he is and for all feedings after that when the baby is that food is nearby! He will slowly begin to awake and willing to participate. move towards the breast. Provide support and assist a bit if it seems necessary, but avoid Getting comfortable directing the baby. Your baby will locate the Choose a bed or sofa where you can lean back nipple and latch-on with minimal assistance about half way or more, whatever is comfortable from you. Let your baby lead the way. for you.

This baby located the breast and latched on independently

Page 10 Importance of Skin to Skin contact

Babies tend to feed best when they have direct contact with mother, in skin-to-skin contact. Not only does it keep baby warm, the smells and feel of the breast encourage the baby to locate the breast and begin feeding.

Mix & Match Techniques

You may find that the sandwich hold would help your baby get a deeper latch-on the breast. Place thumb near the baby’s nose and fingers on Sandwich hold the opposite side of the breast, and gently compress the breast into a “sandwich”. Listen for swallows to assure that your baby is drinking milk.

Feel free to use any of the Mother-led Latching techniques from the handout “Mother-led Latching” if they seem to work better at the time.

If you find breastfeeding painful or your baby is not gaining weight (2/3 to 1 oz per day), please seek the help of a lactation consultant to give you personalized guidance.

Although breastfeeding is natural, it is a learning process for both you and your baby. Allow yourself several weeks to perfect these techniques.

At any time that you are unsure that you are feeding correctly, seek the help of a lactation consultant or other knowledgeable health care provider. Once breastfeeding is fully established, it can be one of the most rewarding experiences of new motherhood.

Lactation Education Resources. This handout may be freely duplicated. Please be aware that the information provided is intended solely for general educational and informational purposes only. It is neither intended nor implied to be a substitute for professional medical advice. Always seek the advice of your physician for any questions you may have regarding your or your infant’s medical condition. Never disregard professional medical advice or delay in seeking it because of something you have received in this information. 2016 www.LactationTraining.com

Page 11 SIGNS OF A GOOD LATCH

• The latch feels comfortable to you size of your baby’s mouth. If areola Some babies swallow so quietly that and does not hurt or pinch. How it is showing, you will see more above a pause in their breathing may be the feels is more important than how it your baby’s lip and less below. only sign of swallowing. looks. • When your baby is positioned well, • You see your baby’s ears “wiggle” • Your baby’s chest rests against your his mouth will be filled with breast. slightly. body. She does not have to turn her • Your baby’s tongue is cupped under • Your baby’s lips turn outward like head while nursing. the breast, although you might not fish lips, not inward. • You see little or no areola, depending see it. • Your baby’s chin touches your breast. on the size of your areola and the • You hear or see your baby swallow.

Page15 12 YOUR GUIDE TO BREASTFEEDING

HELP WITH LATCH PROBLEMS

ARE YOU IN PAIN? ARE YOU OR YOUR BABY FRUSTRATED? don’t worry. A weak suck is rarely caused Many moms say their breasts feel tender Take a short break and hold your baby by a health problem. when they first start breastfeeding. A in an upright position. Try holding your mother and her baby need time to find baby between your breasts with your skin COULD YOUR BABY BE TONGUE-TIED? comfortable breastfeeding positions and touching his or her skin (called skin-to- Babies with a tight or short lingual a good latch. If breastfeeding hurts, your skin). Talk or sing to your baby, or give frenulum (the piece of tissue attaching baby may be sucking on only the nipple. your baby one of your fingers to suck on the tongue to the floor of the mouth) Gently break your baby’s suction to your for comfort. Try to breastfeed again in a are described as “tongue-tied.” The breast by placing a clean finger in the little while. medical term is ankyloglossia. Babies corner of your baby’s mouth. Then try who are tongue-tied often find it hard again to get your baby to latch on. To find DOES YOUR BABY HAVE A WEAK SUCK OR MAKE ONLY to nurse. They may be unable to extend out whether your baby is sucking only TINY SUCKLING MOVEMENTS? their tongue past their lower gum line on your nipple, check what your nipple Your baby may not have a deep enough or properly cup the breast during a feed. looks like when it comes out of your latch to suck the milk from your breast. This can cause slow weight gain in the baby’s mouth. Your nipple should not Gently break your baby’s suction and try baby and nipple pain in the mother. If look flat or compressed. It should look again. Talk with a lactation consultant or you think your baby may be tongue-tied, round and long or the same shape it was pediatrician if you are not sure whether talk to your doctor. before the feeding. your baby is getting enough milk. But

A good latch is important for your baby to breastfeed effectively and for your A GOOD LATCH comfort. During the early days of breastfeeding, it can take time and patience for your baby to latch on well.

BREASTFEEDING HOLDS

Some moms find that the following pillows under your arms, elbows, neck, for one feeding may not work for the next positions are helpful ways to get or back to give you added comfort and feeding. comfortable and support their babies support. Keep trying different positions while breastfeeding. You also can use until you are comfortable. What works

Page 13 CLUTCH OR “FOOTBALL” HOLD: useful if you CROSS-CRADLE OR TRANSITIONAL HOLD: useful for CRADLE HOLD: an easy, common hold that have had a C-section, or if you have premature babies or babies with a weak is comfortable for most mothers and large breasts, flat or inverted nipples, suck because this hold gives extra head babies. Hold your baby with his or her or a strong let-down reflex. This hold is support and may help the baby stay head on your forearm and his or her also helpful for babies who like to be in latched. Hold your baby along the area body facing yours. a more upright position when they feed. opposite from the breast you are using. Hold your baby at your side with the Support your baby’s head at the base of baby lying on his or her back and with his or her neck with the palm of your his or her head at the level of your nipple. hand. Support your baby’s head by placing the palm of your hand at the base of his or her head.

LAID-BACK HOLD (STRADDLE HOLD): a more SIDE-LYING POSITION: useful if you have had relaxed, baby-led approach. Lie back a C-section, but also allows you to rest on a pillow. Lay your baby against your while the baby breastfeeds. Lie on your body with your baby’s head just above side with your baby facing you. Pull your and between your breasts. Gravity and baby close so your baby faces your body. an instinct to nurse will guide your baby to your breast. As your baby searches for your breast, support your baby’s head and shoulders but don’t force the latch. Page 14

17 YOUR GUIDE TO BREASTFEEDING

TIPS FOR MAKING IT WORK

LEARN YOUR BABY’S HUNGER SIGNS. breast at each feeding. Help your baby can show you ways that are supportive When babies are hungry, they are more finish the first breast as long as she is still of breastfeeding. These include feeding alert and active. They may put their sucking and swallowing. Your baby will your baby with a syringe, a small, flexible hands or fists to their mouths, make let go of your breast when she is finished. cup, or a tiny tube taped beside your sucking motions with their mouth, or Offer her the other breast if she seems to nipple. Try to give your baby expressed turn their heads looking for the breast. want more. milk first. However, unless your baby is If anything touches their cheek, such as unable to feed well, it’s best to feed at a hand, they may turn toward the hand, KEEP YOUR BABY CLOSE TO YOU. the breast. ready to eat. This sign of hunger is called Remember that your baby is not used rooting. Offer your breast when your to this new world and needs to be held MAKE SURE YOUR BABY SLEEPS SAFELY AND CLOSE BY. baby shows rooting signs. Crying can be a close and comforted. Skin-to-skin contact Have your baby sleep in a crib or late sign of hunger, and it may be harder between you and baby will soothe his bassinet in your bedroom so that you can for the baby to latch if he is upset. Over crying and also will help keep your baby’s breastfeed more easily at night. Research time, you will be able to learn your baby’s heart and breathing rates stable. A soft has found that when a baby shares a cues for when to start feeding. carrier, such as a wrap, can help you bedroom with his parents, the baby has “wear” your baby. a lower risk of SIDS. FOLLOW YOUR BABY’S LEAD. Make sure you and your baby are AVOID NIPPLE CONFUSION. If your baby falls asleep at the breast comfortable, and follow your baby’s lead Avoid using pacifiers and bottles for the during most feedings, talk to your baby’s after she is latched on well to your breast. first few weeks after birth unless your doctor about having the baby’s weight Some babies will feed from (or “take”) doctor has told you to use them because checked. Also, see a lactation consultant both breasts, one after the other, at each of a medical reason. If you need to use to make sure your baby is latching feeding. Other babies take only one supplements, work with an IBCLC. She on well.

Babies need 400 International Units (IU) of vitamin D each day. Ask your baby’s VITAMIN D doctor about supplements in drop form. Learn more about vitamin D and your baby’s needs on page 29.

MAKING PLENTY OF MILK

Your breasts will easily make and supply to double their weight in a few short Most mothers can make plenty of milk milk for your baby’s needs. The more months, and their tummies are small, so for their baby. If you think you have a low often your baby breastfeeds, the more they need many feedings to grow and be milk supply, talk to a lactation milk your breasts will make. Babies try healthy. consultant. See page 6 for other types of health professionals who can help you.

Page 15 Many leading health organizations recommend that most infants breastfeed for at least 12 months, with exclusive breastfeeding for the first six months. This means that babies are not given any foods or liquids other than breastmilk for the first six months. HOW LONG SHOULD I BREASTFEED? These recommendations are supported by organizations including the American Academy of Pediatrics, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, American College of Nurse- Midwives, Academy of Nutrition and Dietetics, and American Public Health Association.

WHAT WILL HAPPEN WITH YOUR MILK, YOUR BABY, AND YOU IN THE FIRST FEW WEEKS

TIME MILK BABY YOU (MOM)

BIRTH Your body makes Your baby will probably be awake in You will be tired and colostrum (a rich, thick, the first hour after birth. This is a good excited. yellowish milk) in small time to breastfeed your baby. amounts. It gives your baby early protection against diseases.

FIRST 12–24 HOURS Your baby will drink It is normal for the baby to sleep heavily. You will be tired, too. about 1 teaspoon of Labor and delivery are hard work! Some Be sure to rest. colostrum at each feeding. babies like to nuzzle and may be too sleepy You may not see the to latch at first. Feedings may be short colostrum, but it has what and disorganized. Take advantage of your your baby needs and in baby’s strong instinct to suck and feed upon the right amount. waking every couple of hours.

NEXT 3–5 DAYS Your mature (white) Your baby will feed a lot, most likely 8 to Your breasts may feel milk takes the place of 12 times or more in 24 hours. Very young full and leak. (You colostrum. It is normal breastfed babies do not eat on a schedule. can use disposable or for mature milk to have It is okay if your baby eats every 2 to 3 cloth pads in your bra a yellow or golden tint at hours for several hours, then sleeps for 3 to to help with leaking.) first. 4 hours. Feedings may take about 15 to 20 minutes on each breast. The baby’s sucking rhythm will be slow and long. The baby might make gulping sounds.

FIRST 4–6 WEEKS White breastmilk Your baby will now likely be better at Your body gets used continues. breastfeeding and have a larger stomach to breastfeeding. Your to hold more milk. Feedings may take less breasts may become time and may be further apart. softer and the leaking may slow down.

Page19 16 YOUR GUIDE TO BREASTFEEDING

HOW TO KNOW YOUR BABY IS GETTING ENOUGH MILK

Many babies, but not all, lose a small first week of age. From birth to 3 months • Your baby switches between short amount of weight in the first days after old, typical weight gain is two-thirds to 1 sleeping periods and wakeful, alert birth. Your baby’s doctor will check your ounce each day. periods. baby’s weight at your first doctor visit • Your baby is satisfied and content after you leave the hospital. Make sure Other signs that your baby is getting after feedings. to visit your baby’s doctor for a checkup plenty of milk: • Your breasts may feel softer after you within three to five days after birth and • Your baby passes enough clear or feed your baby. then again when the baby is 2 to 3 weeks pale yellow urine. The urine is not old. deep yellow or orange. Talk to your baby’s doctor if you are • Your baby has enough bowel worried that he or she is not getting You can tell whether your baby is getting movements (see the chart on the next enough milk. plenty of milk. He will be mostly content page). and will gain weight steadily after the

At birth, your baby’s stomach can comfortably digest what would fit in a hazelnut (about 1 to 2 THE NEWBORN TUMMY teaspoons). By around 10 days, your baby’s stomach grows to hold about 2 ounces, or what would fit in a walnut. Hazelnut Walnut

Page 17 A newborn’s tummy is very small, especially in the early days. Once breastfeeding is established, exclusively breastfed babies who are HOW MUCH DO BABIES 1 to 6 months old take in between 19 TYPICALLY EAT? and 30 ounces of breastmilk each day. If you breastfeed your baby eight times a day, your baby will get about 3 ounces per feeding. But every baby is different.

TYPICAL NUMBER OF WET DIAPERS AND BOWEL MOVEMENTS IN A BABY’S FIRST WEEK (IT IS FINE IF YOUR BABY HAS MORE) 1 DAY = 24 HOURS

NUMBER OF NUMBER OF BOWEL COLOR AND TEXTURE OF BABY’S AGE WET DIAPERS MOVEMENTS BOWEL MOVEMENTS

DAY 1 1 The first one usually occurs Thick, tarry, and black (first 24 hours after birth) within 8 hours after birth.

DAY 2 2 3 Thick, tarry, and black

DAY 3 5–6 disposable, 3 Looser greenish to yellow 6–8 cloth (color may vary)

DAY 4 6 3 Yellow, soft, and watery

DAY 5 6 3 Loose and seedy, yellow color

DAY 6 6 3 Loose and seedy, yellow color

DAY 7 6 3 Loose and seedy, yellow color

Page21 18 YOUR GUIDE TO BREASTFEEDING

COMMON CHALLENGES

Breastfeeding can be challenging at you and your baby. And while many baby that they don’t have with their other times, especially in the early days. women are faced with one or more of the babies. Read on for ways to troubleshoot But remember that you are not alone. challenges listed here, many women do problems. Lactation consultants can help you find not struggle at all! Also, many women ways to make breastfeeding work for may have certain problems with one

Ask a lactation consultant for help to improve your baby’s latch. Talk to your doctor if your pain does not go away or if you suddenly get sore nipples after several weeks of pain-free breastfeeding. Sore nipples may lead to a breast infection, which needs to be treated by a doctor.

CHALLENGE: SORE NIPPLES

Many moms say that their nipples feel • If you find yourself wanting to delay device that covers the nipple while tender when they first start breastfeeding. feedings because of pain, get help breastfeeding). Some women should Breastfeeding should be comfortable from a lactation consultant. Delaying not use these products. Your doctor once you and your baby have found a feedings can cause more pain and will help you make the choice that is good latch and some positions that work. harm your milk supply. best for you and your baby. • Try changing positions each time • Don’t wear bras or clothes that are WHAT YOU CAN DO you breastfeed. too tight and put pressure on your • A good latch is key, so see page 13 for • After breastfeeding, express a few nipples. detailed instructions. If your baby drops of milk and gently rub it on • Change nursing pads (washable or sucks only on the nipple, gently your nipples with clean hands. disposable pads you can place in break your baby’s suction to your Human milk has natural healing your bra to absorb leaks) often to breast by placing a clean finger in the properties and oils that soothe. Also, avoid trapping in moisture. corner of your baby’s mouth and try try letting your nipples air-dry after • Avoid harsh soaps or ointments that again. (Your nipple should not look feeding or wear a soft cotton shirt. contain astringents (like a toner) on flat or compressed when it comes out • Get help from your doctor or your nipples. Washing with clean of your baby’s mouth. It should look lactation consultant before using water is all that is needed to keep round and long, or the same shape as creams, hydrogel pads (a moist your nipples and breasts clean. it was before the feeding.) covering for the nipple to help ease • If you have very sore nipples, you can soreness), or a nipple shield (a plastic ask your doctor about using non- aspirin pain relievers.

Page 19 CHALLENGE: LOW MILK SUPPLY

Most mothers can make plenty of milk the breast. It’s also normal for your try pumping afterward. The more for their babies. But many mothers worry baby to continue to nurse for 10 or often you empty your breasts, the about having enough milk. Checking 15 minutes on each breast at each more milk your breasts will make. your baby’s weight and growth is the best feeding or to prefer one breast over • Offer both breasts at each feeding. way to make sure he gets enough milk. the other. Each baby is different. Have your baby stay at the first breast Let your baby’s doctor know if you are • Growth spurts can cause your baby as long as he or she is still sucking concerned. to want to nurse longer and more and swallowing. Offer the second often. These growth spurts can breast when the baby slows down or For more ways to tell if your baby is happen when your baby is around 2 stops. getting enough milk, see page 19. to 3 weeks, 6 weeks, and 3 months of • Try to avoid giving your baby age. Growth spurts can also happen formula or cereal in addition to your THERE MAY BE TIMES WHEN YOU THINK YOUR SUPPLY at any time. Don’t be worried that breastmilk. Otherwise, your baby IS LOW, BUT IT IS ACTUALLY JUST FINE. your milk supply is too low to satisfy may lose interest in your breastmilk, • When your baby is around 6 weeks your baby. Follow your baby’s lead. and your milk supply will then to 2 months old, your breasts may Nursing more often will help build decrease. If you need to supplement no longer feel full. This is normal. up your milk supply. Once your your baby’s feedings, try using a (It’s also normal for some women supply increases, you will likely be spoon, syringe, cup, or dropper filled to never experience “full” breasts.) back to your usual routine. with breastmilk. At the same time, your baby may • Limit or stop your baby’s use of a nurse for only a short time, such as WHAT YOU CAN DO pacifier while, at the same time, five minutes at each feeding. These • Make sure your baby is latched on trying the above tips. are not signs of a lower milk supply. and positioned well. • Check with your doctor for health The mother’s body adjusts to meet • Breastfeed often and let your baby issues, such as hormonal issues or the needs of her baby, and the baby decide when to end the feeding. If primary breast insufficiency, if the gets very good at getting milk from your baby does not empty the breast, above steps don’t help.

Talk to your baby’s doctor if you think your baby is not getting enough milk.

Page 20 YOUR GUIDE TO BREASTFEEDING

CHALLENGE: OVERSUPPLY OF MILK

Some mothers worry about an the next full feeding, gradually swelling. oversupply of milk. An over-full breast increasing the length of time • Feed your baby before he or she can make breastfeeding stressful and per feeding. becomes overly hungry to prevent uncomfortable for you and your baby. • If the other breast feels too full aggressive sucking. (Learn more before you are ready to breastfeed on about hunger signs on page 17.) WHAT YOU CAN DO it, hand express for a few moments • Burp your baby often if he or she • Breastfeed on one side for each to relieve some of the pressure. You is gassy. feeding. Continue to offer that same also can use a cold compress or breast for at least two hours until washcloth to reduce discomfort and

Ask a lactation consultant for help if you are unable to manage an oversupply of milk on your own.

CHALLENGE: STRONG LET-DOWN REFLEX

Some women have a strong milk ejection WHAT YOU CAN DO • If your baby chokes or sputters when reflex or let-down, which can cause a • Hold your nipple between your first breastfeeding, gently break the latch rush of milk. This can happen along with and middle fingers or with the side and let the excess milk spray into a an oversupply of milk. of your hand. Lightly compress your towel or cloth. milk ducts to reduce the force of the • Allow your baby to come on and off milk ejection. the breast at will.

CHALLENGE: ENGORGEMENT

It is normal for your breasts to become Engorgement sometimes also causes a Engorgement can lead to plugged ducts larger, heavier, and a little tender when low-grade fever and can be confused with or a breast infection (see page 25), so it is they begin making milk. Sometimes, a breast infection. Engorgement is the important to try to prevent it before this this fullness may turn into engorgement, result of the milk building up. It usually happens. If treated, engorgement should which is when your breasts feel hard happens during the third to fifth day fix itself. and painful. You also may have breast after giving birth. But it can happen at swelling, tenderness, warmth, redness, any time, especially if you are not feeding throbbing, and flattening of the nipple. your baby or expressing your milk often.

Ask your lactation consultant or doctor for help if the engorgement lasts for two or more days.

Page 21 CHALLENGE: ENGORGEMENT (CONT.)

WHAT YOU CAN DO • Hand express or pump a little milk • Wear a well-fitting, supportive bra • Breastfeed often after giving birth. to first soften the breast, areola, and that is not too tight. As long as your baby is latched on nipple before breastfeeding. • Try reverse pressure softening to and sucking well, allow your baby to • Massage the breast. make the areola soft around the base nurse for as long as she likes. • Use cold compresses on your breast of the nipple and help your baby • Work with a lactation consultant to in between feedings to help ease the latch. Try one of the holds in the improve your baby’s latch. pain. illustrations on the left. Press inward • Breastfeed often on the affected side • If you plan to return to work, try to toward the chest wall and count to remove the milk, keep the milk pump your milk as often as your slowly to 50. Use steady and firm moving freely, and prevent your baby breastfed at home. Be sure to pressure, but gentle enough to avoid breast from becoming overly full. not let more than four hours pass pain. You may need to repeat each • Avoid using pacifiers or bottles to between pumping sessions. time you breastfeed for a few days. supplement feedings. • Get enough rest, proper nutrition, and fluids.

SIX ENGORGEMENT HOLDS*:

1. One-handed “flower hold.” Works best 2. Two-handed, one-step method. Works 3. Use the two-handed, one-step method. if your fingernails are short. Curve your best if your fingernails are short. Curve You may ask someone to help press by fingertips in toward your body and place your fingertips in toward your body and placing fingers or thumbs on top of yours. them where baby’s tongue will go. place them on each side of the nipple.

4. Two-handed, two-step method. Using 5. Two-handed, two-step method. Using 6. Soft-ring method. Cut off the bottom two or three fingers on each side, place straight thumbs, place your thumbnails half of an artificial nipple and place it on your first knuckles on either side of the evenly on either side of the nipple. Move the areola. Press with your fingers. nipple and move them 1/4 turn. Repeat 1/4 turn and repeat above and below the above and below the nipple. nipple.

Page 22 YOUR GUIDE TO BREASTFEEDING

CHALLENGE: PLUGGED DUCT

Plugged ducts are common in WHAT YOU CAN DO • Use a warm compress on the sore breastfeeding mothers. A plugged milk • Breastfeed on the affected side as area. duct feels like a tender and sore lump in often as every two hours. This will • Get extra sleep, or relax with your the breast. You should not have a fever or help loosen the plug and keep your feet up to help speed healing. Often other symptoms. milk moving freely. a plugged duct is a sign that a mother • Aim your baby’s chin at the plug. is doing too much. A plugged duct happens when a milk This will focus his suck on the duct • Wear a well-fitting supportive bra duct does not drain properly. Pressure that is affected. that is not too tight, since this can then builds up behind the plug, and • Massage the area, starting behind constrict milk ducts. Consider trying surrounding tissue gets inflamed. A the sore spot. Move your fingers in a a bra without underwire. plugged duct usually happens in one circular motion and massage toward • If you have plugged ducts that keep breast at a time. the nipple. coming back, seek help from an IBCLC.

If your plugged duct doesn’t loosen up, ask for help from a lactation consultant. Plugged ducts can lead to a breast infection.

CHALLENGE: BREAST INFECTION (MASTITIS)

Mastitis is soreness or a lump in the one breast. It is not always easy to tell • Massage the area, starting behind breast. It can cause the following the difference between a breast infection the sore spot. Move your fingers in a symptoms: and a plugged duct. They have similar circular motion and massage toward • Fever or flu-like symptoms, such as symptoms and can improve within 24 to the nipple. feeling run down or very achy 48 hours. Some breast infections that do • Apply heat to the sore area with a • Nausea not improve within this time period need warm compress. • Vomiting to be treated with medicine from your • Get extra sleep, or relax with your • Yellowish discharge from the nipple doctor. (Learn more about medicines feet up to help speed healing. Often that looks like colostrum and breastfeeding on page 29.) a breast infection is a sign that a • Breasts feel warm or hot to the touch mother is doing too much and and appear pink or red WHAT YOU CAN DO becoming overly tired. • Breastfeed on the affected side every • Wear a well-fitting supportive bra A breast infection can happen when two hours or more often. This will that is not too tight, since this can other family members have a cold or the keep the milk moving freely and your constrict milk ducts. seasonal flu. It usually only happens in breast from becoming overly full.

Page 23 Ask your doctor for help if you do not feel better within 24 hours of trying these tips, if you have a fever, or if your symptoms worsen. You might need medicine.

SEE YOUR DOCTOR RIGHT AWAY IF: • You have a breast infection in which both breasts look affected. • There is pus or blood in your breastmilk. • You have red streaks near the affected area of the breast. • Your symptoms came on severely and suddenly.

Also, talk with your doctor about any medicines you take or plan to take.

CHALLENGE: FUNGAL INFECTIONS

A fungal infection, also called a yeast • Pink, flaky, shiny, itchy, or cracked very hot water (above 122°F). infection or thrush, can form on your nipples • Wear a clean bra every day. nipples or in your breast. This type of • Deep pink and blistered nipples • Wash your hands often. infection thrives on milk and forms from • Achy breasts • Wash your baby’s hands often, an overgrowth of the Candida organism. • Shooting pains deep in the breast especially if he sucks on his fingers. Candida lives in our bodies and is kept during or after feedings • Boil all pacifiers, bottle nipples, healthy by the natural bacteria in our or toys your baby puts in her bodies. When the natural balance of WHAT YOU CAN DO mouth every day. After one week of bacteria is upset, Candida can overgrow, Fungal infections may take several treatment, throw away all pacifiers causing an infection. weeks to clear up, so it is important to and nipples and buy new ones. follow these tips to avoid spreading the • Boil all breast pump parts that touch Signs of a fungal infection include: infection: your milk every day. • Nipple soreness that lasts more than • Change disposable nursing pads • Make sure other family members a few days, even after your baby has a often. are free of thrush or other fungal good latch • Wash any towels or clothing that infections. If they have symptoms, come in contact with the yeast in make sure they get treated.

If you or your baby has symptoms of a fungal infection, call both your doctor and your baby’s doctor so you can be correctly diagnosed and treated at the same time. This will help prevent passing the infection to each other.

I had a terrible time learning to nurse my son. My nipples were terribly sore, and it felt like it wasn’t getting any better. After visiting my doctor, the lactation consultant, and the pediatrician, it became clear that a horrible case of thrush had been the source of my pain. I honestly did not think I would make it, but I was too stubborn to quit, and I am grateful I stuck with it. I am proud to say that I breastfed my son until he was 16 months old! – Jessica, Edmonton, Alberta, Canada 27 Page 24 YOUR GUIDE TO BREASTFEEDING

CHALLENGE: NURSING STRIKE

A nursing “strike” is when your baby has • Being upset about a long separation WHAT YOU CAN DO breastfed well for months and suddenly from the mother or a major change • Try to express your milk as often as begins to refuse the breast. A nursing in routine the baby used to breastfeed to avoid strike can mean that your baby is trying • Being distracted while breastfeeding, engorgement and plugged ducts. to let you know that something is wrong. such as becoming interested in other • Try another feeding method This usually does not mean that the baby things going on around the baby temporarily to give your baby your is ready to wean. • Having a cold or stuffy nose that breastmilk, such as using a cup, makes breathing while breastfeeding dropper, or spoon. Not all babies will react the same way difficult • Keep track of your baby’s wet and to the different things that can cause a • Getting less milk from the mother dirty diapers to make sure she gets nursing strike. Some babies will continue after supplementing breastmilk with enough milk. to breastfeed without a problem. Other bottles or overuse of a pacifier • Keep offering your breast to your babies may just become fussy at the • Responding to the mother’s strong baby. If your baby is frustrated, stop breast. And other babies will refuse the reaction if the baby has bitten her and try again later. You can also offer breast entirely. while breastfeeding your breast when your baby is very • Being upset by hearing arguing or sleepy or is sleeping. Some of the major causes of a nursing people talking in a harsh voice while • Try different breastfeeding positions, strike include: breastfeeding with your bare skin next to your • Having mouth pain from teething, a • Reacting to stress, overstimulation, baby’s bare skin. fungal infection like thrush, or a cold or having been repeatedly put off • Focus on your baby, and comfort him sore when wanting to breastfeed with extra touching and cuddling. • Having an ear infection, which • Breastfeed while rocking your baby causes pain while sucking or If your baby is on a nursing strike, it in a quiet room free of distractions. pressure while lying on one side is normal to feel frustrated and upset, • Feeling pain from a certain especially if your baby is unhappy. Be breastfeeding position, perhaps from patient with your baby and keep trying to an injury on the baby’s body or from offer your breasts. soreness from an immunization

Be sure to feed your baby during a nursing strike to ensure that your baby gets enough milk. The doctor can check your baby’s weight gain.

Page 25 CHALLENGE: INVERTED, FLAT, OR VERY LARGE NIPPLES

Some women have nipples that turn Very large nipples can make it hard for • The latch for babies of mothers with inward instead of pointing outward, the baby to get enough of the areola into very large nipples will improve with or that are flat and do not protrude. his or her mouth to compress the milk time as the baby grows. It might take Nipples also can sometimes flatten for ducts and get enough milk. several weeks to get the baby to latch a short time because of engorgement or well. But if you have a good milk swelling from breastfeeding. Inverted WHAT YOU CAN DO supply, your baby will get enough or flat nipples can sometimes make it • Talk to your doctor or a lactation milk even with a poor latch. harder to breastfeed. But remember, consultant if you are concerned for breastfeeding to work, your baby about your nipples. must latch on to both the nipple and the • You can use your fingers to try and breast, so even inverted nipples can work pull your nipples out. You also can just fine. Often, flat and inverted nipples use a special device that pulls out will protrude more over time as the baby inverted or temporarily flattened sucks more. nipples.

Ask for help if you have questions about your nipple shape or type, especially if your baby is having trouble latching well.

Page 26 29 YOUR GUIDE TO BREASTFEEDING

GOING BACK TO WORK

Planning ahead for your return to work can help ease the transition. Learn as much as you can ahead of time and talk with your employer about your options. This can help you continue to enjoy breastfeeding your baby long after your maternity leave is over.

DURING YOUR MATERNITY LEAVE

• Take as many weeks off as you can. the workday. A hands-free breast infants 3 to 4 months old). Babies At least six weeks of leave can help pump may even allow you to work used to nursing might prefer a bottle you recover from childbirth and while pumping if you have a laptop or cup when it’s given by someone settle into a good breastfeeding or an office with a door that you else. Wait at least a month before routine. Twelve weeks is even better. can close. See pages 38 to 42 for introducing a bottle to your infant. • Practice expressing your milk by more information about pumping • Talk with your family and your child hand or with a breast pump. A breast and storage. care provider about your desire to pump may be the best method for • Help your baby adjust to taking breastfeed. Let them know you will efficiently removing milk during breastmilk from a bottle (or cup for need their support.

BACK AT WORK

• Keep talking with your supervisor • If your child care is close by, find out to breastfeed first. This will give about your schedule and what is or whether you can visit to breastfeed you both time to reconnect before isn’t working for you. Keep in mind over lunch. traveling home and returning to that returning to work gradually • When you arrive to pick up your other family responsibilities. gives you more time to adjust. baby from child care, take time

Page 27 Information for breastfeeding families Hand Expression

Hand expression is a handy skill to have whenever you need to empty your breasts and you are not with your baby or your baby is temporarily unable to breastfeed. In the first few days after birth, hand expression can be more effective at removing colostrum than using a breast pump. If your baby needs a supplement in the first week or so, use hand expression to provide the milk he needs!

Hand expression routine: 2 5 1. Apply heat, massage and stroke breasts 2. Position fingers behind areola 3. Press back toward the chest 4. Compress fingers together to express milk 5. Relax and repeat, getting a rhythm going 3 7 6. Express for 5-7 minutes 7. Move fingers to a different position 8. Massage and stroke the breast 9. Press back toward the chest 4 9 10. Compress fingers together to express milk 11. Express milk for 3-5 minutes 12. Massage and stroke breasts 13. Move fingers to a different position 14. Express milk for 1-2 minutes 10 15. Complete cycle takes 20-30 minutes

Watch these videos while you are hand expressing to see the technique in action! • http://newborns.stanford.edu/Breastfeeding/HandExpression.html • https://vimeo.com/65196007

Provided for you by Lactation Education Resources. May be freely copied and distributed. Please be aware that the information provided is intended solely for general educational and informational purposes only. It is neither intended nor implied to be a substitute for professional medical advice. Always seek the advice of your physician for any questions you may have regarding your or your infant’s medical condition. Never disregard professional medical advice or delay in seeking it because of something you have received in this information.

Page 28 Information for breastfeeding families Hands-on Pumping

Using a breast pump is important if your baby is ill, premature or unable to breastfeed for any reason. You will obtain more milk from the pumping session if you use breast massage at the same time. You will have more milk to save for feedings and your milk supply will increase.

Hands on pumping routine:

▪ Begin breast pumping within 6 hours of delivery ▪ Use a hospital grand breast pump with a double pump kit 8 times or more per 24 hours ▪ Does not need to be a regular schedule, do whenever convenient ▪ Assure the flanges are appropriate size ▪ Nipple moves freely in and out during suction cycle ▪ Breasts are emptied completely, no areas of lumps ▪ No pain while pumping Watch this video while ▪ No white ring around areola you are pumping! ▪ Wear a bra or bustier that will hold the flanges in place while you pump so your hands can be free http://med.stanford.edu/newborns/ for massaging professional- ▪ Start with slow massage to stimulate let-down education/breastfeeding/maximizing ▪ Apply the breast pump and use the maximum -milk-production.html suction level that is comfortable, not painful ▪ Watch the sprays of milk and adjust hand position to where milk flows the most easily ▪ When the sprays of milk subside, switch to single pumping so you can be more vigorous with the massage ▪ When the sprays of milk subside again, turn off the pump and hand massage into the pump flange. Some mothers can double their output this way. This is hind milk, the richest milk for the baby. ▪ Pay special attention to the outer margins of the breast Provided for you by Lactation Education Resources. May be freely copied and distributed. Please be aware that the information provided is intended solely for general educational and informational purposes only. It is neither intended nor implied to be a substitute for professional medical advice. Always seek the advice of your healthcare provider for any questions you may have regarding your or your infant’s medical condition. Never disregard professional medical advice or delay in seeking it because of something you have received in this information. 2016.

Page 29 Accessible version: www.cdc.gov/healthywater/hygiene/healthychildcare/infantfeeding/breastpump.html How to Keep Your Breast Pump Kit Clean Providing breast milk is one of the best things you can do for your baby’s health and development. Pumping your milk is one way to provide breast milk to your baby. Keeping the parts of your pump clean is critical, because germs can grow quickly in breast milk or breast milk residue that remains on pump parts. Following these steps can help prevent contamination and protect your baby from infection. If your baby was born prematurely or has other health concerns, your baby’s health care providers may have more recommendations for pumping breast milk safely.

BEFORE EVERY USE Wash hands with soap and water.

Inspect and assemble clean pump kit. If your tubing is moldy, discard and replace immediately.

Clean pump dials, power switch, and countertop with disinfectant wipes, especially if using a shared pump.

AFTER EVERY USE

Store milk safely. Cap milk collection bottle or seal milk collection bag, label with date and time, and immediately place in a refrigerator, freezer, or cooler bag with ice packs.

Clean pumping area, especially if using a shared pump. Clean the dials, power switch, and countertop with disinfectant wipes.

Take apart breast pump tubing and separate all parts that come in contact with breast/breast milk.

Rinse breast pump parts that come into contact with breast/breast milk by holding under running water to remove remaining milk. Do not place parts in sink to rinse.

Clean pump parts that come into contact with breast/breast milk as soon as possible after pumping. You can clean your pump parts in a dishwasher or by hand in a wash basin used only for cleaning the pump kit and infant feeding items.

Follow the cleaning steps given on the next page.

Page 30 Clean Pump Kit CLEAN BY HAND Place pump parts in a clean wash basin used only for infant feeding items. Do not place pump parts directly in the sink! Add soap and hot water to basin. Scrub items using a clean brush used only for infant feeding items. Rinse by holding items under running water, or by submerging in fresh water in a separate basin. Air-dry thoroughly. Place pump parts, wash basin, and bottle brush on a clean, unused dish towel or paper towel in an area protected from dirt and dust. Do not use a dish towel to rub or pat items dry! Clean wash basin and bottle brush. Rinse them well and allow them to air-dry after each use. Wash them by hand or in a dishwasher at least every few days.

OR CLEAN IN DISHWASHER Clean pump parts in a dishwasher, if they are dishwasher-safe. Be sure to place small items into a closed-top basket or mesh laundry bag. Add soap and, if possible, run the dishwasher using hot water and a heated drying cycle (or sanitizing setting). Remove from dishwasher with clean hands. If items are not completely dry, place items on a clean, unused dish towel or paper towel to air-dry thoroughly before storing. Do not use a dish towel to rub or pat items dry!

After Cleaning FOR EXTRA PROTECTION, SANITIZE For extra germ removal, sanitize pump parts, wash basin, and bottle brush DISHWASHERDISHWASHER 6000 6000 at least once daily after they have been cleaned. Items can be sanitized using steam, boiling water, or a dishwasher with a sanitize setting. Sanitizing is especially Heavy Duty Normal Fast Sanitize Rinse important if your baby is less than 3 months old, was born prematurely, or has a weakened immune system due to illness or medical treatment.

For detailed instructions on sanitizing your pump parts, visit www.cdc.gov/healthywater/hygiene/healthychildcare/infantfeeding.html

STORE SAFELY Store dry items safely until needed. Ensure the clean pump parts, bottle brushes, and wash basins have air-dried thoroughly before storing. Items must be completely dry to help prevent germs and mold from growing. Store dry items in a clean, protected area.

Learn more about safe and healthy diapering and infant feeding

habits at www.cdc.gov/healthywater/hygiene/healthychildcare. CS277601A

Page 31 Expressing Your Milk for Your Baby Your milk is the best food for your baby. Some babies have difficulty breastfeeding right away. If your baby is not breastfeeding well yet, you will need to remove milk from your breasts as many times as your baby would normally feed in order to let your body know you want to make milk for your baby. Wash your hands before expressing your milk. Express at least 8 times or more in a 24 hour day, including at night, so about every 2 to 3 hours during the day and about every 3 to 4 hours at night. Keep going until you reach full milk production, which is normally about 25 to 30 oz / (750 to 900 ml) total in a 24 hour day. Once you build up your supply to full production (which normally will take about 2 to 4 weeks), most mothers can slowly decrease minutes of pumping and then number of sessions after that, while carefully maintaining volume. It’s very important to track your milk production on a chart or an app to know how much you are making at first. You can use your hands or a breast pump to express milk. Many mothers find it difficult to remove the first thick milk, colostrum, with a breast pump. Hand expression is a useful technique to remove this first milk. When your breasts feel fuller, try the hands - on pumping method to help you remove more milk, by massaging your breasts while you pump. When pumping, if your arms are getting tired, you can buy or make a pumping band or bra.

How Often Should I Express Milk? Day 1 until about Day 4 Build Up Volume - Maintain Full Milk (when breasts feel fuller) Day 3 or 4 to Full Milk Production Combine both pumping Production About 25 to 30 Oz and hand expression (25 to 30 Ounces Daily) Per Day Per Baby Number of Sessions At least 8 At least 8 5-8 Pump 15 min* 20 to 30 min About 10-20 min Hand expression About 10 minutes Use hands-on pumping Use hands-on pumping *During the first 24 hours in the hospital, use the Initiate setting on the Symphony breast pump. After 24 hours, use the maintain setting.

How Much Breast Milk Should I Feed My Baby? Breast Milk per Feeding Average Amount Total per 24 Hour Day Day 1 1 to 5 ml* 15 to 30 ml Day 2 2 to 15 ml* 15 ml to 4 oz Day 3 15 to 30 ml 3 to 8 oz. Day 4 and 5 30 to 50 ml 8 to 12 oz. Day 6 to 7 60-90ml (2-3 oz.) 14 to 18 oz. 1 to 2 weeks 60 to 90 ml (2-3 oz.) 16 to 20 oz. 2 weeks to 1 mo. 60 to 120 ml (2-4 oz.) 16 to 25 oz. 1 to 6 months 90 to 120 ml (3-4 oz.) About 25 oz. One ounce = 30 ml *Some mothers get a little more or less colostrum on the first and second day. Usually we just give whatever you can collect. Milk volumes are approximate amounts and may vary based on your individual baby, their size, their feeding patterns and health. Consult your Pediatrician for more information about how much to feed your baby as well.

Page 32 Most babies tend to drink a little more formula than human milk. Formula fed infants will often drink larger volumes and space out their feedings more. Infants that are fed with human milk tend to bottle-feed more on a breastfed baby schedule. Their feedings are smaller and more frequent. For example, by one month, breast fed babies average about 25 oz. total volume per day. This is about 3 to 4 oz per feeding every 2 to 3 hours. While baby’s fed formula may take closer to 30 oz and about 4 to 5 oz per feeding. By 6 months, most babies fed formula will take about 6 to 8 oz at around 4 or 5 feeds per day. While those fed their mother’s milk will typically continue to eat closer to 4 oz per feed. Infant’s that are fed their mom’s milk also have less gas, spitting up, constipation and risk of obesity. Your milk is absorbed and digested most easily by your infant. Whenever you collect milk for your baby place one of the baby’s patient labels on the bottle and write the date and time you pumped. If your baby is in the nursery, please bring the milk to the nursery refrigerator. Please do not store breast milk in your room refrigerator. To thaw frozen or refrigerated milk place in a bowl or cup of water water. Never microwave breast milk or formula.

Human Milk Storage Times

Place Temperature How Long Things to Know Room Temperature Best = 5 hours Keep container covered Countertop Freshly Pumped 60-85 Degrees F Acceptable = 6-8 hours Cooler with Ice Pack 59 Degrees F 24 hours Limit opening cooler Up to 39 Degrees F Best = 72 hours Store in the back of the Refrigerator, fresh never frozen Acceptable = 5-8 days refrigerator Refrigerator thawed, Up to 39 Degrees F Use within 24 hours Once taken out of fridge use previously frozen within 1 to 2 hours 0 Degrees F or less Best = 3 to 6 months Store at the back of the freezer, Freezer Or 6 to 12 months in deep use oldest milk first chest freezer When bottle-feeding your baby, we recommend pacing the feeds. For more information, view, “Paced Bottle-feeding for the Breast Fed Baby,” which can be found on Youtube. More advice from the American Academy of Pediatrics: “The most important thing to remember, whether you breastfeed or bottle-feed, is that your baby’s feeding needs are unique. No book can tell you precisely how much or how often he needs to be fed or exactly how you should handle him during feedings. You will discover these things for yourself as you and your baby get to know each other.” Breastfeeding Answers Made Simple, Nancy Mohrbacher. 2010. P. 472. AAP. Healthchildren.org. Amount and Schedule of Formula Feedings. 2015. Human Milk Banking Association of North America. Best Practice for Expressing, Storing and Handling Human Milik. 3rd Ed. 2011.

Page 33 reastfeeding L B Is Baby Getting Enough Milk . Baby’s Stomach . Changing Stools . Diaper Count

L L Let your baby show you how long to breastfeed. Once baby has fed well on one our babys stools will change breast and stops and lets go, burp your baby and then offer the other breast to see if they are still hungry. Day 1-3 - Black, thick and sticky; this is called meconium. You should hear or see your baby swallow while nursing.

Your baby should breastfeed 8-12 times in 24 hours. Day 3-4 - Greenish to yellow and is less thick.

By day 5 - Mustard or yellow seedy and watery. en Egg Chick rge La = ze Your baby’s stomach is very Si h ac m ng Ball small and will not take very to g Po S Pin 0 = 1 e y iz a S much at each feeding. h D ac ou can tell when your baby is getting enough mil by m to S le the number of diapers they use. our baby should wet/ M a r b At left is the size of 3 er oot y Sh a = dirty the following number of diapers per day. D e Siz h your baby’s ac m to BABY’S AGE WET DIAPERS DIRTY DIAPERS S 1 y stomach. a D 1 DAY OLD

et help from your doctor or lactation consultant if your baby 2 DAYS OLD Has a dry mouth. 3 DAYS OLD Has red colored urine. Has yellow skin (Jaundice). 4 DAYS OLD

Stool does not change to yellow and seedy by day 5. 5 DAYS OLD Does not have enough wet or dirty diapers (see Breastfeeding Diaper Diary on back). 6+ DAYS OLD Does not wake up to eat at least 8 times in 24 hours. Is losing weight after day 5; is under birth weight at 2 weeks. After 4-6 weeks of age your baby’s stools may or decrease. It is not unusual You may not be able to express very You are experiencing nipple pain. for breastfed babies older much breast milk at first. This is than 1 month to only stool normal and does not mean you do L every 2-4 days or longer. not have enough milk . If your baby is feeding every hour this is called cluster feeding and it is perfectly normal. Example: Baby breastfeeds every hour for 3-5 feedings WWW.HEALTH.MO.GOV and sleeps 3-4 hours between clusters.

Page 34 Each day, circle the approximate time to the nearest hour that you start breastfeeding. Circle the when your baby has a wet diaper. Circle the when your baby has a dirty diaper.

Black Tarry Dirty Diaper D

Black Tarry Dirty Diaper D D

Green Dirty Diaper D D

Green Dirty Diaper D D D

Yellow Dirty Diaper D D D

Yellow Dirty Diaper D D D D

Yellow Dirty Diaper D D D D f you have any concerns or uestions about breastfeeding call

MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES WIC AND NUTRITION SERVICES 573-751-6204 AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER Services provided on a nondiscriminatory basis. 568 (10/11) Page 35 Notes

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9200 W. Wisconsin Ave. Milwaukee, WI 53226 1-800-DOCTORS (1-800-362-8677) froedtert.com

PE-01967 (05/18)