Index Breastfeeding your Baby How Breast Feeding works
1 Index Breastfeeding your Baby How Breast Feeding works Let-Down The signs of milk release The signs of a sluggish let-down Treatment measures for let-down difficulty What is Breast Milk? Types of Nipples Common Nipples Large Nipples Flat or Small Nipples Inverted Nipples Treatment for Flat, Dimpled or Inverted Nipples Care for your Nipples and Breasts Care before feeds Bras Care after feeds Nursing pads Shells Breastfeeding Positions Finding a comfortable position for nursing Good nursing position Sitting up Football hold Lying down Feedings Feeding times How long should feedings be? “Latching on” Burping Is baby getting enough milk? Concerns about Baby Sleepy baby Growth spurts Bowel movements Treatment measures for refusal to nurse Difficulty” latching on” Treatment measures for the baby who stops nursing Spitting an vomiting Pulling away from the breast Use of pacifiers Concerns about Yourself Engorged breasts Tips to help with engorgement Plugged ducts 3 3 4 4 4 5 5 6 6 6 6 6 6 7 7 7 7 7 7 8 8 8 8 9 9 10 10 10 10 11 12 13 13 13 13 14 14 15 15 15 16 17 17 17 17 2 Mastitis Sore nipples Breast pain Overabundant milk Leaking milk Breast Massage Fingertip Massage Warm washcloth application Diamond hand position Parallel hand position How to massage during feedings Pumping Breast pumps Developing and maintaining a milk supply through pumping How to pump (single pump) How to pump (double pump) Storage of breast milk How much breast milk should you leave for your baby for each feeding Storage guidelines Expressing breast milk by hand Babies with special needs Alcohol, tobacco and drugs Nutrition Fluids Find your balance between food and physical activity Know the limits on fats, sugars and salts Vary your Veggies Focus on fruits Get your calcium rich foods Go lean with protein Supplemental feeding Weaning from breastfeeding Menses Postpartum sexuality Contraception Breastfeeding log for the first week of life 18 19 21 21 21 21 21 22 22 22 22 24 24 25 25 26 26 27 27 27 28 28 29 29 29 29 29 29 30 30 31 32 32 32 33 34 3 Breastfeeding Your Baby Breastfeeding is recommended by the American Academy of Pediatrics. Breast milk is the ideal infant food for the first year of life, and can protect your baby from illness and allergies. Breastfeeding is convenient for mother since it is always ready. It helps the uterus return to normal and promotes a warm secure feeling and an emotional bond. Breastfeeding is your baby’s first immunization. It provides protection from gastrointestinal and respiratory illness. Breast milk will also reduce the incidence of allergies and provides added immunologic protection. Breastfeeding is a commitment and although natural, is something for mother and baby to learn together. Sometimes it takes a few days for both of you to feel comfortable and to know what to expect from each other. Be patient and persistent. Relax and enjoy each other. How Breastfeeding Works Your milk is made by many clusters of milk-producing cells which fill the back of your breast. From each of these clusters runs a tiny tube (duct) that carries the milk forward. The ducts empty milk into small pockets, called the main milk ducts, beneath the areola. Each milk duct narrows down to another tiny tube which goes to a nipple opening. You have about 4 to 18 of these openings. When your baby starts sucking at your breast, a reflex is triggered. Your breast receives a signal to release milk from the milk-producing cells. The milk flows down through the ducts. Then, as your baby’s lips press down on the sinuses that lie just below your areola, milk is squeezed into the nipple openings. That is why it is important for baby to have as much of the areola in his mouth as possible. 4 Let-Down During the early weeks of breastfeeding, the let-down response, also known as the milk ejection reflex, is developing. Sometimes mothers are told that they must be happy, relaxed, and carefree for the let-down of milk to occur. If this were the case, few women would ever succeed at nursing. Although many mothers worry that their milk won’t be available as needed, let-down failure is extremely rare among women who nurse regularly and often. For the establishment and maximal functioning of the let-down reflex, nurse your baby every 11/2 to 3 hours during the day and on demand at night for at least the first two to three weeks of life. Make sure your baby is positioned correctly and is compressing the sinuses beneath the areola, and that the feeding time is not limited. Ideally, your baby should be allowed — encouraged, if necessary — to nurse at least 10 to 20 minutes at each breast. It is also important that you are as comfortable as possible. The milk may not release completely if you are experiencing pain. A warm shower or warm compresses to your breast will promote letdown. The signs of milk release during the first week (will vary for each woman): Mild uterine cramping during nursing. Increased vaginal flow during nursing. Dripping, leaking, or spraying milk, especially during nursing. Occasional tingling sensations in the breast during nursing. Softening of the breasts after nursing (this may not be noticeable during the period of initial engorgement, two to four days postpartum). Feeling of relaxation, thirst or sleepiness. None or only occasional sensation. Swallowing sound The most reliable indicator of milk let-down is the sound of your baby swallowing. As the milk releases, your baby will swallow after every couple of sucks. A typical rhythm is suck-suck-suckswallow-suck-suck-swallow. The swallowing pattern may occur steadily over several minutes or may come in surges of two or three minutes at a time. The signs of a sluggish let-down usually include all of the following: No cramping. No leaking of milk. No sign of breasts softening after nursing. No swallowing, or swallowing during only the first minute or two of nursing (your baby may then swallow only occasionally or pull away from your breast crying). 5 Often when a mother believes she is experiencing a let-down difficulty, the problem is actually with the baby’s latch-on or sucking. Treatment Measures for Let-Down Difficulty: Nurse regularly, frequently, and for as long as the baby wants. Make yourself as comfortable as possible before nursing. If necessary take your prescribed pain medication at least one-half hour before nursing. Nurse in a relaxing place. Drink a cool beverage during your nursing to encourage let-down. Before nursing, apply moist heat to your breasts and spend several minutes gently massaging them. Try manually expressing or pumping a small amount of milk to encourage the flow to begin. Carefully position your baby at your breast. Be sure that your baby is pulled in very close to you. The football hold may help the baby nurse more efficiently. Make sure your baby is latching on and sucking correctly. Your baby should have strong, steady suction while nursing, and you should not hear frequent clicking noises or see dimples in the baby’s cheeks. Massage your breasts during the entire feeding, and practice slow, deep breathing. Switch breasts if you do not hear swallowing within five minutes. Continue switching breasts every five minutes if swallowing is infrequent. Ask for outside help if you are not hearing swallowing after a few feedings. Seeing a lactation professional may be helpful. What is Breast Milk? Although formula preparation tries to imitate mother’s milk, no preparation is exactly the same as breast milk. The more formula companies study breast milk, the more they seem to find other ingredients that are important to an infant’s development. It is highly unlikely that human breast milk will ever be exactly reproduced. Colostrum is the “early milk” your baby will receive the first 2-3 days. It is yellow in color. There is only a small amount of colostrum in each breast per feeding. This is all the baby will require until your milk comes in. Although similar to breast milk, its composition makes it easier for baby to digest than the mature milk you will produce later. Another important advantage of colostrum is that it contains a great number of special antibodies which researchers believe help newborns to resist illness. Within two to five days after birth, colostrum is replaced with mature milk. Breast milk is completely digested within 90 minutes. This milk contains many different components that are important for the development of your baby. The amount of milk produced will vary. Milk is produced on a supply and demand basis. Your breast milk contains a large amount of vitamins A and E, some vitamin C and small amounts of vitamins D and K. This milk has twice as much iron as cow’s milk and contains calcium and phosphorus. Breast milk contains special proteins 6 that will be used by the body. Human milk is lower in saturated fats. Breast milk composition changes according to your baby’s age and nutritional needs. Although cow’s milk is lower in sugar content, the sugar in breast milk seems to protect the intestinal tract from bacteria. Breast milk looks much thinner than cow’s milk or formula, and is white with a blue tint. As you continue to nurse, your milk will appear “creamier.” This is because the fat content becomes higher towards the end of the feeding. Your body produces the perfect food for your baby’s first few months of life, and the American Academy of Pediatrics recommends exclusive breastfeeding for the first six months of life. Types of Nipples Common Nipples: These do not require any special preparation for breastfeeding. The “pinch test” is done by pinching your areola next to your nipple between your index finger and thumb. If your nipple protrudes and continues to after you pinch it, then your nipples should be fine for nursing. Large Nipples: Try manual expression to soften the areola and make it more pliable before putting the infant to your breast. Breast shells may help if your nipples are also flat, but in most cases just working patiently with your baby is all that is needed. (Breast shells are explained in this section on page F-5 for flat, dimpled or inverted nipples.) BREASTFEEDING YOUR BABY Flat Nipples or Small Nipples: If there is no noticeable protrusion of the nipple unless manually stimulated, compress the breast and areola between two fingers to provide as much nipple as possible to your baby. A breast shell used between feedings will draw the nipple out. A breast pump used between or before feedings will also help the nipple protrude. Inverted Nipples: If your nipple moves inward or remains flattened as you do the pinch test, then you need to help prepare your nipples to protrude. You can do this by obtaining and wearing breast shells. In most cases, you can start using breast shells in the middle of your pregnancy and continue using until nursing is well established. If you have flat or inverted nipples, ask your doctor when you can start wearing shells. If you have not started to wear them while pregnant, you can begin wearing them after you deliver. Using a breast pump before or between feedings will also help. TREATMENT FOR FLAT, DIMPLED OR INVERTED NIPPLES Treatment for Flat, Dimpled or Inverted Nipples: One or more of the following suggestions may help you: Breast shells worn inside of your bra gently force your nipple to push out by putting constant pressure against your areola. Small air vents in the plastic dome admit air to the skin to avoid irritation. 7 Stimulate the nipples by gently stroking or rolling them between your thumb and forefinger. Apply ice around the nipple just before the baby attempts to feed. Pump your breast prior to nursing for about a minute on each side or until milk begins flowing and the nipple is protruding. Express a few drops of milk onto your nipple or your baby’s lips then stimulate the baby to suck and protrude the nipple. BREASTFEEDING YOUR BABY Care For Your Nipples and Breasts Care before Feeds: Your daily bath or shower is sufficient for cleaning your breasts. Avoid getting soap or shampoo on the nipple and areola; it tends to counteract the naturally occurring oils that cleanse this area and cause dry nipples, cracking and discomfort. Antiseptic applications to the nipples are also unnecessary and may be harmful. Always wash your hands before breastfeeding or pumping. Bras: You may want to wear a nursing bra for convenience, comfort and support, especially after your milk comes in. Bras with cotton rather than synthetic cups allow for better air circulation to the nipples. If wearing an underwire bra, be sure it is well fitted and no areas of pressure exist. Care after Feeds: If baby does not come off the breast when the nursing session is over, release the suction by slipping a clean finger in between the baby’s jaws and gently pulling down until the suction is released. Leave your breasts exposed to the air for five to ten minutes before covering up. Air drying is soothing to the nipples. Although for years mothers have used breast creams on their nipples, these do not prevent or reduce nipple soreness. In fact, a number of nursing women have developed sore nipples as a result of unsuspected allergies to preparations containing lanolin, vitamin E or cocoa butter. Any preparation that comes with instructions to wash it off before nursing is best avoided, as frequent washing is overly drying to the nipples. Pure lanolin, such as Purlan 100 or Lansinoh, may be used sparingly and does not need to be washed off. Colostrum can be expressed onto the nipples to lubricate them. Nursing Pads: Nursing pads are usually necessary during this time to prevent wet or spotted clothing. You can buy bra pads in two varieties: reusable, washable types, and disposable types. (Remember: if using a disposable pad, stay away from those with plastic liners because they keep the nipple wet and may aggravate soreness.) Shells: If you are using plastic breast shells to improve the shape of your nipples, you may find during the first few weeks that they cause your milk to leak excessively and keep your nipples damp. You might try placing the shells in your bra just 20 to 30 minutes before the feeding (milk collected this way must be discarded). Don’t routinely use breast shells in place of nursing pads, since they probably cause more leakage. Breast shells should be washed after each nursing in hot soapy water and rinsed thoroughly. 8 Breastfeeding Positions Finding a Comfortable Position for Nursing Successful breastfeeding requires taking the time and effort to find good positions for nursing. One of the most exciting findings of recent years is the importance of positioning for good suckling. It has been found that many women with sore nipples, and babies who failed to gain weight could be traced to poor positioning at the breast. By readjusting nursing positions, both of these problems are often cleared up. When you find two or three comfortable positions, alternate them. This will help to prevent sore nipples by changing the area where the baby puts the most pressure when latched on to the breast. It will also serve to stimulate different milk ducts, and prevent clogged ducts. A good nursing position should incorporate the following: You are supported in such a way that you can hold the position for some time without feeling cramped or stiff; you are not hunched over, trying to bring the breast to your baby; instead, you bring your baby to the breast. Baby’s nose is directly facing the nipple. When baby latches on, the head will tilt upward and baby will be close enough to take much or all of the areola into the mouth while nursing. Sitting Up Sit straight up in bed or in a comfortable chair or couch, with your back and head supported by one or more big pillows if necessary. Put your baby on a pillow on your lap in order to bring the mouth to nipple level. Raise one or both knees to bring your baby closer to your body. It may help to support your foot on the side from which your baby is nursing by resting it on a chair rung, a footstool, or a large book. Your baby should be lying on his side so he does not have to turn his head to reach the nipple. Baby’s face, abdomen, genitals, and knees should all be facing your body. The pelvis should be up against your abdomen with your baby’s lower arm under your arm and around your waist. Your arm on the side of the nursing breast supports the head as you hold your baby in the crook of your elbow. Your arm is extended as far down the baby’s back as possible, with your hand holding the buttocks or upper thigh, keeping your baby as close to your body as you can. The knees are held across your other breast, so that your baby is in a horizontal, not diagonal position. Pillows or folded blankets may be used to provide support for your arm or the baby. BREASTFEEDING YOUR BABY 9 Football Hold: In this position you tuck your baby under your arm like a football. His head rests on a pillow on your lap; the feet are on your side. This position is good for Caesarean mothers, since the baby’s legs cannot kick or put pressure on the incision. It’s also good for twins and mothers with large breasts. Some babies who don’t suck properly in the other positions do well this way. Lying Down: For the first few days after your baby’s birth and for night feedings afterward, you may find it most restful to lie down to nurse. To nurse lying down, lie on your side with one or two pillows behind your back and one or two under your head. A flat pillow (made of folded cloth diapers, a receiving blanket, or a towel) placed under your baby’s head as he lies facing you will put his mouth at breast level and make it easier for him to reach the nipple. Your bottom arm can be up and out of the way, or under his head, cradling him. If you had a Caesarean birth, ask your nurse to help you get into a comfortable position. They want to help you. Keep your legs bent, with a pillow between your knees. Ask the nurse to place something firm at the bottom of your bed so you can push your feet against it. There are two ways to shift from nursing on one side to the other. One is to nurse your baby on the bottom breast, then to tuck that breast under your bottom arm and to lean over and nurse with the top breast. At the next feeding you switch sides. The other way of changing involves nursing on one side, then pulling your baby over onto your stomach and rolling both you and your baby over to your other side, using the guard-rail on the side of the bed to help. Ask the nurse to show you how. 10 Feedings Feeding Times The optimum time for feeding is when baby is in a quiet, alert state, rather than when the baby is crying. Your baby should nurse approximately 8 to 12 times in 24 hours by the 3rd day of life. We encourage you to nurse your infant every 1 1/2 hours if he is awake or wake him in 3 hours during the day or evening if he is still sleeping since the last feed. This will encourage him to take many longer “naps” at night time. Some babies may need to nurse more frequently if they sleep for long periods. They may cluster feed then sleep longer. For example, from noon to 11 pm, the baby may feed eight times then sleep up to five hours. To awaken baby for feeding, try these tips — unbundle the baby, change the diaper, stimulate the bottom of the feet, stroke, pat the back or do “baby sit-ups.” When feeding baby at night try to provide minimal stimulation so he knows this is not play time. Change your baby’s diaper between breasts with low lights, talk quietly and put your baby back to bed right after feeding. You should offer both breasts at each feeding, but it can be normal for baby to only nurse on one breast. Start with the side you finished with at the last feeding or the breast the baby did not nurse from. You may want to attach a safety pin to your bra on this side as a reminder for your next feeding. How Long Should Feedings Be? In the beginning, breastfeeding is a learning process for both you and the baby. It’s not necessary to time feedings. A general rule is to try to encourage the baby to nurse at least 10 minutes on each side. Hindmilk, the milk highest in fat content which is necessary for baby’s growth, usually can be seen after five minutes of nursing, but this can vary. The first few days of breastfeeding your baby may not meet this goal, but if there are adequate wet diapers and stools your baby is getting enough. Initially, baby will take short rapid sucks until a let-down occurs. Once let-down occurs, the sucking pattern changes to rhythmic, longer sucks. Your baby will take short rest periods — if, after a reasonable time the baby doesn’t start to suck, gently lift his chin upward or stroke the side of his face for encouragement. Burp your baby after the first breast and offer the second breast until content. As they grow older, some babies will nurse only a short time at each breast or take only one breast at a feeding and still have a steady weight gain. Once a weight gain pattern is noted, let your baby determine the length and frequency of the feeding. “Latching On” “Latching on” refers to baby’s grasp on your nipple. This is a skill that is learned over the first few days of breastfeeding. “Rooting” refers to your baby’s natural reflex to root or turn toward a stimulus, such as your finger or nipple stroking his cheek. To stimulate rooting, touch your nipple to baby’s cheek. Your baby will turn toward the nipple. 11 Where you put your hand to help shape the breast varies by hold. If you hold your baby in front on his side, shape your thumb and fingers like a “U.” If you hold your baby along your side, shape your fingers more like a “C.” Remember that your fingers should run in the same direction as your baby’s mouth. Adjust your baby’s body so he is facing you (not turned or twisted), with feet, hips and shoulders in a straight line, and pressed firmly against you with no gaps. Align your baby so that his nose is in line with your nipple. Let his head tilt back a bit (Avoid pushing on the back of your baby’s head.) Gently touch your baby’s lips with the nipple. Baby probably will respond by opening his mouth wide. (Stroke from the upper lip downward.) o You can also assist your baby in opening his/her mouth by using your finger to gently pull down on the chin. Lift the breast slightly so the nipple points straight ahead or slightly downward. Then draw the baby close to latch on to your breast. Note that the nipple and as much of the areola as possible, especially the lower portion, are in baby’s mouth. If the nostrils are blocked while your baby is nursing, lift the breast slightly with the hand that is supporting it. Proper positioning decreases/prevents sore nipples. Baby’s nose and chin are facing the breast, do not push on the breast to make room for breathing. This can cause plugged ducts which can lead to decreased milk supply and breast infection. Babies who have trouble breathing while nursing will pull off the breast. In correct positioning your baby’s lips should surround the nipple. There should not be any dimpling of the cheeks as baby sucks and baby should not be easily removed from your breast. You may notice your baby’s ear wiggle, or jaw movement as she sucks. You should not hear any smacking or clicking noises while your baby is nursing. You should be able to draw an imaginary straight line from the baby’s ear to shoulder to hip in the cradle or cross-cradle position. BREASTFEEDING YOUR BABY Burping To take baby off your breast, insert your finger into the corner of baby’s mouth between the gums and press down on the lower jaw. This enables baby to release your breast and prevents sore nipples. You need to burp your baby several times during a feeding: after each breast, if fussy or pulling away and after the last breast. This helps to remove any air your baby has swallowed while sucking. Naturally, a breast-fed baby swallows less air than a bottlefed baby, so burping occurs less with nursing babies, and sometimes not at all. There are three ways to burp your baby: 12 1. You can lay your baby cross-ways on your lap, belly down, and pat or rub baby’s back. 2. You can hold your baby up to your shoulder, supporting the head and back with one hand, while patting or rubbing with the other. 3. You can sit your baby upright on your lap, lean the baby’s weight forward with one hand supporting his chin and chest, and pat or rub his back gently with the other hand. Some babies tend to spit-up more than others and may need to be burped more often. Spitting up usually subsides after the first year. If your baby is vomiting frequently or forcefully, (usually the amount that would fill an adult hand, spitting up is less than this) your baby’s doctor should be notified. Is Baby Getting Enough Milk? There are ways to tell if your baby is getting enough to drink: You should be able to see and hear your baby swallowing by the third or fourth day. Breasts that are firm at the beginning of a feeding will soften after a feeding. Baby should experience progressive weight gain, noted by the doctor, after an initial weight loss in the first and second days of life. Baby gains an average of 4 to 6 ounces a week in the first month and 6 to 8 ounces a week during the next three months. Baby seems content after feeding. Do not: Do not compare your baby’s weight gain with other babies. Different babies gain weight at different rates of speed. Do not test for hunger by offering your baby a bottle after nursing. Many infants have such a strong urge to suck that they’ll often take milk from a bottle even when not hungry. This will cause overfeeding and can increase the tendency to spit up. 13 Concerns About Baby Sleepy Baby Most babies will be sleepy for the first 24 to 48 hours after birth. Babies can also be sleepy up to 12 hours after a circumcision. This is a normal occurrence that will not interfere with the nursing process. Some suggestions to wake a sleepy baby include: Unwrap baby. Change the diaper. Rub the small of baby’s back in a circular motion. Tickle the bottom of baby’s feet. Talk to baby. Stroke your baby’s forehead with a “cool” (not cold) wash cloths Baby situps. The sleepy baby needs routine scheduled feedings rather than a “demand schedule” until baby begins waking on her own. This is necessary for baby’s well-being and also ensures milk production and supply. Be patient and persistent during this period. If all else fails, try again in a half hour. Your baby will become more alert and show interest in breastfeeding as her appetite increases. Growth Spurts You may notice at different times during the first year that your baby may want to nurse more frequently and can’t seem to get enough milk. These periods occur at fairly predictable times: Approximately 7-10 days of age, 2 to 3 weeks, 6 weeks, 3 months, and 6 months. These spurts usually last about 24 to 48 hours and are referred to as growth spurts. Your baby may want to nurse every 11/2 to 2 hours or sooner, and may exceed 12 feedings in 24 hours. You should nurse as often as your baby wants to and at about 48 hours your baby will probably space feedings again. Your breasts respond to this extra demand and produce more milk to satisfy your baby’s hunger. Don’t worry about spoiling your baby with these extra feedings. Many mothers tend to blame themselves for their babies crying, wondering if their inexperience, nervousness, or milk supply is somehow responsible. Most babies fuss and seek out the comfort of the breast when they are tired, lonely or uncomfortable. Some babies naturally need to suck more than others. BREASTFEEDING YOUR BABY Bowel Movements Your baby’s first few stools are called meconium. Meconium is black, greenish-black or dark brown and is tarry and sticky. By the second or third day after several colostrum feedings, the baby will have passed most of the meconium; he may have a few greenish-brown or brownishyellow transitional stools. When breast milk production is established, the stools take on a yellow or mustard color and “seedy” texture. This usually occurs by the fourth or fifth day. This yellow stool is a sign that your baby is getting a sufficient amount of breast milk. Most babies have at least four bowel movements daily by the end of the first week. Many have up to 12 14 (although some only have one). For the first six weeks, stools are loose or may even be runny. These should not be confused with diarrhea (a stool that is watery with no substance and has a foul odor). These breast milk stools will have a sweet or cheesy odor. When other foods are added, colors and odors will change. Your baby may pass his stools easily, or he may fuss, grunt and turn red in the face. This is not constipation. Constipation is unlikely as long as your baby is totally breast-fed. Treatment Measures for Refusal to Nurse Continue working with your baby. Short, frequent sessions may be less upsetting for both of you. If someone is working with you, the side-lying position may give her the greatest control and visibility. These sessions can become intense and sometimes upsetting, so let your helper know when you or your baby needs a break. Nipple shields or bottle nipples are not generally recommended for placement over the breast to encourage your baby to nurse. There are some breastfeeding problems, which may benefit from the use of a nipple shield. Your nurse or lactation consultant will assist in their use if you experience these problems. Although your baby may latch on to an artificial nipple, the shield may not allow for adequate nipple stimulation or for the necessary compression of the sinuses beneath the areola. This can seriously hamper the let-down of milk and adequate emptying of the breast, which may lead to a poor milk supply and insufficient intake for your baby. Some babies become accustomed to the shield and will refuse to nurse without it. If you use a shield, talk to a lactation consultant about how to maintain an adequate milk supply. If, after 24 to 48 hours, your baby has not latched on, supplementary feedings should begin. Manually express or pump your milk at least eight times a day, and feed your baby using a cup, a spoon or a bottle and nipple. You may contact a lactation consultant or breastfeeding educator for other feeding methods, such as cup feeding, fingerfeeding and supplemental nursing systems. If you are discharged from the hospital and your baby is still not nursing, obtain an electric pump and continue giving your milk to the baby, by your chosen method. Your nurse or lactation consultant will discuss options with you. Continue short practice sessions several times a day. Some babies do better on a soft or empty breast. Have the baby’s doctor rule out any medical reasons. Refusal of one breast: It is common for some babies to prefer one breast over another, especially in the beginning. Continue to offer both breasts. Many times this preference will disappear when the milk comes in. Get lots of support and encouragement. If possible, see a lactation consultant. Difficulty “Latching-On” “Latch-on” difficulties can originate with the baby or the mother. Most occur when the baby is sleepy; when the breast becomes overly full or engorged; or when the mother has flat, dimpled, or inverted nipples. Problems other than these are discussed as follows. 15 Refusal to nurse after having previously nursed During the first week, it is not uncommon for a baby who has already nursed to suddenly refuse one or both sides. He may simply act uninterested although he is awake, or he may protest furiously when put to one or both breasts. A baby who has been given a bottle or pacifier during the first week may become “nipple confused” and refuse to nurse. If this happens, your baby will likely start nursing again after a few hours or after one or more of the following measures are taken. Treatment measures for the baby who stops nursing Soften the areola if you are overly full or engorged by using manual expression or a pump just before putting the baby to breast. Calm the frantic baby. A few drops of colostrum or glucose water on baby’s lips or dripped over the nipple will often alert and encourage the baby. Occasionally a very upset baby may need to be tightly swaddled in a thin blanket before attempting to nurse. Pay attention to proper positioning. When the baby’s face turns from side to side with mouth wide open, pull the baby closer so their tongue can feel the nipple. Try letting the baby suck on your finger for a few seconds just before putting him to breast. Persist. The baby who is hiccupping, having a bowel movement, or staring at his mother will usually be reluctant to latch on. Try again in about a half-hour. Coax the baby who is suddenly refusing one breast by using the football hold on that side. Offer your breast when the baby is sleepy. Hold the baby skin-to-skin. BREASTFEEDING YOUR BABY Spitting and Vomiting Spitting up small amounts of breast milk is common; some babies do this after almost every nursing. In cases of spitting up, the baby will show no signs of illness. Occasionally, baby may vomit what seems like an entire feeding, but he still may be doing fine. If you are worried, keep track of the number of wet diapers and bowel movements. Call your baby’s doctor with signs of illness. Pulling Away from the Breast Babies pull off the breast while nursing for a variety of reasons. Often it is because they have had enough to eat, they need to be burped or they are distracted. If your baby has a cold, he may pull away because of trouble breathing through his nose. Try nursing in the football hold with his head elevated more during the feeding. A cool-mist vaporizer may help to thin the nasal secretions for easier breathing. Some babies pull away from the breast, gasping and choking as the milk suddenly lets down. Babies gradually learn to keep up with the rapid flow of milk. Positioning your baby differently 16 may help. Try sitting your baby up, using the football hold, sitting back in an easy chair or lying on your back to nurse with baby on top of your chest. The last position uses gravity to slow the flow of milk to baby. Some mothers manually express or pump milk until the initial spray has subsided then put the baby to the breast to nurse. Use of Pacifiers Use of a pacifier is often associated with a shortened duration of breastfeeding. If one is used, an orthodontic pacifier should be purchased. Occasionally a breast-fed baby may become nipple confused. For that reason we suggest you wait three weeks before using a pacifier. Babies use different muscles to suck when using a pacifier. When they are then breast-fed, sucking on the breast this way can cause your nipples to become sore. Discontinue the use of the pacifier if your baby has difficulty latching on or your nipples become sore. At no time should the pacifier be used as substitute for breastfeeding. If you use a pacifier, be sure you are still nursing your baby often enough to maintain a full milk supply. 17 Concerns About Yourself Engorged Breasts Engorgement is a fullness of the breasts ranging from mild firmness to painful swelling and is experienced by many breastfeeding women. It will usually occur about three to five days postpartum. Engorgement is caused by an increased amount of blood and body fluid going to the breasts, as well as the pressure of the newly produced milk. Severe engorgement is caused when the baby is not nursing well or feedings are missed. Engorgement will usually begin to subside within 12 to 48 hours. It is important not to become discouraged during this period. Remember that this is a normal process and will not last forever. Tips to Help with Engorgement: Feed your baby every one to three hours. Many babies will nurse 10 to 20 minutes on each breast. This may mean waking a sleeping baby. Wear a supportive bra between nursings, and take it off when nursing, so all areas of the breast can be emptied. Moist heat can be applied before nursing to help the milk flow out of the ducts. This can be done by placing warm towels on the breasts for five minutes or more or by showering. If the nipple area is too swollen for the baby to grasp, take a warm shower, hand express or pump some milk to help soften the breasts. During nursing, massage your breasts from the outside toward the areola to help empty the entire breast. Apply ice packs to breasts between feedings, but only for 20 minutes, after a feeding of at least 10 minutes per side. This will help to relieve swelling and discomfort. Wear breast shells 30 minutes before each feeding. Avoid pumping milk for engorgement except to soften the areola or when baby is refusing to feed from one or both breasts. If your baby doesn’t relieve the fullness by nursing, you may pump enough milk after the feeding to feel comfortable. Engorgement that is not relieved can decrease your milk supply. Cabbage leaves can be used as a home remedy. Their effectiveness has not been scientifically proven, but many women find them soothing. To use, remove outer leaves, rinse refrigerated cabbage leaves, strip the large vein and cut a hole for the nipple. Apply the leaves directly to your breasts inside your bra. Only wear for 20 minutes after a feeding of 10 to 20 minutes, per breast. No more than three applications in 24 hours or milk supply can decrease. REASTFEEDING YOUR BABY Plugged Ducts A plugged milk duct is caused by a diminished flow of milk from an area of your breast. Milk will build up and form a blockage in your milk duct. Blocked ducts are more common during the early weeks of nursing, during the winter months in mothers with high milk production, and in 18 mothers who have twins. They may also occur when your baby weans or sleeps through the night or if you become fatigued. Common causes of this may be: The breast is not emptied with each feeding. Infrequent nursing. Rapid weaning. Tight fitting bras (underwire types may obstruct the milk flow) or tight clothing. Pressure on breasts during feeding with a finger to make breathing space for baby. Symptoms of Plugged Ducts include: At first you may notice breast pain or discomfort in a section of your breast. Later you will feel a hard, lumpy area which is sometimes very tender and does not disappear or decrease in size after nursing. It will come on gradually and may shift location. You may feel little or no warmth in the area and feel generally well. WHAT TO DO FOR A PLUGGED DUCT: What to do for a plugged duct: Frequent nursing, at least every two to three hours. Position baby with his chin close to the plugged duct to promote better drainage. Allow your baby to nurse for a few minutes longer than usual to help empty your breast. Start baby’s feeding on the affected breast. Apply warm, moist heat to the affected breast before each feeding and between feedings for your comfort. Continue to nurse or pump. If you stop suddenly your breast will become fuller and more painful. Massage affected area while nursing to help milk flow through the affected duct. Be sure you are drinking plenty of fluids, and getting enough rest. You may take Ibuprofen (Motrin) or Acetaminophen (Tylenol) for the general discomfort you may be experiencing. Express or pump milk from the affected breast if it has been more than three or four hours since your baby last nursed. Do not sleep on your stomach or put pressure on your breasts. Offer the sore breast first so that the baby will empty it. BREASTFEEDING YOUR BABY Mastitis Mastitis is an infection in your breast which will not affect the breast milk your baby receives when you nurse. Plugged ducts, cracked nipples, tight bras, wet breast pads, stress, fatigue and anemia can all lead to mastitis. You can help prevent mastitis by nursing frequently, by using good hand washing techniques, eating a good diet and finding time to rest. One or both breasts may be affected. 19 Symptoms of Mastitis: Often starts as a plugged duct. Breast pain or discomfort in a generalized area of the breast. Hard, red, lumpy area of your breast which is sometimes very hot and swollen. This will not disappear or decrease in size after nursing. Flu like symptoms including headache, exhaustion, aching joints, fever (temperature 101° degrees Fahrenheit or higher), and chills. WHAT TO DO FOR MASTITIS: What to do for Mastitis: You should notify your obstetrician. Your doctor will prescribe an antibiotic for you to take. You should continue this medication as directed even though you are feeling better after a few days. Your doctor realizes you are breastfeeding and will prescribe an antibiotic that is safe to take while you are nursing. Do not stop nursing your baby. Nurse frequently, at least every two to three hours. Allow your baby to nurse for a few minutes longer than usual to help empty the breast. Offer the affected breast first. Pump after a feeding for no more than 10 minutes to make sure the breasts are empty. Your baby will not get ill since the infection involves only the breast tissue not the milk. Apply warm, moist heat to the affected breast before each feeding, and in between feedings for your comfort. Massage affected area while nursing to help milk flow through the affected duct. Be sure you are drinking plenty of fluids, and getting enough rest. You may take Ibuprofen (Motrin) or Acetaminophen (Tylenol) for the general discomfort you may be experiencing. After a feeding you may apply cool compresses or cold cabbage leaves for comfort measures, no longer than 15 to 20 minutes. Sore Nipples If your nipples become sore, review positioning and latching on. Remember to position baby’s mouth over your areola, not just the nipple. Always break your baby’s suction by placing a finger into the corner of the baby’s mouth after nursing. Nipple tenderness at the beginning of a feeding may be normal in the first two to seven days of breastfeeding. The following measures will help while your nipple is healing: Express a little milk manually before putting your baby to your breast to start the milk flowing and to help your let-down operate more quickly. Practice a relaxation technique just before nursing. Warm compresses before a feeding may help your milk flow faster. Nurse your baby more frequently, but for shorter periods of time. Your breasts are less likely to overfill and your baby is more likely to suckle gently. 20 Offer the less-sore breast first. This will give your milk a chance to let-down, and your baby won’t be sucking as hard on the second breast. Change your position at each feeding. Hold your baby in different positions so that you can equalize the pressure on your breast. If a scab forms on your nipple during early nursing, leave it alone. To ease pain, apply crushed ice, wrapped in a wet washcloth, or a washcloth that has been dampened and put in the freezer briefly, to your nipples before a feeding. Avoid all irritating substances. Do not use soap, alcohol, tincture of benzoin or witch hazel on your nipples. Do not wipe away milk left on your breast after a nursing. Let it dry there; it will promote healing. Wear breast shells in between feedings. Keep your nipples dry. If you wear breast pads, change them when they get wet. If you wear breast shells (milk cups), empty them often. You may want to put cotton in the bottom to absorb leaking milk. Leave your nipples uncovered as much as possible. Undo your bra flaps under your clothing occasionally. Occasionally sore nipples are caused by thrush, a fungus infection in the baby’s mouth. Look in your baby’s mouth prior to a feeding. If your baby has milky white spots or a coating on her tongue, gums, or on the insides of her cheeks, call the doctor. Rinse your nipples with clear water and air dry them after each nursing. Thrush thrives on milk and moisture. Common symptoms are shooting pain in the breast, burning in the mom’s nipples (during or after a feeding), red irritated nipples or a bright red diaper rash in the infant. o Call your pediatrician who will need to prescribe Nystatin oral suspension for your baby’s mouth. Nystatin nipple cream will need to be prescribed for you by your obstetrician. Continue using the medication even if the symptoms disappear. The symptoms may seem worse for a day or two before they improve. Do not wear rubber or soft plastic nipple shields. Shields are occasionally advised to insulate sore nipples from your baby’s sucking. Shields may not provide the necessary stimulation your breasts need to keep making milk. Shields rarely relieve soreness, and may cause some babies to develop nipple confusion. These are much different from shells. If your nipples are cracked, bleeding or painful, take your baby off the affected nipple for 24 to 48 hours. Nurse on the unaffected breast and, if necessary, give expressed milk by finger feeding, cup, spoon or bottle. A lactation consultant can assist you with alternative feeding methods. Express or pump your milk from the sore breast every three hours, or every time you would ordinarily be nursing. After a 24-hour break gradually resume nursing with short (five-minute) feedings on the sore breast. You may hand express some breast milk before a feeding to stimulate the let-down reflex. Continue to express milk at other feeding times until your breast is healed enough to work up to the full nursing schedule. 21 o If blood is noted in your milk you can continue to nurse (Baby may spit up blood or have flecks of blood in the stool). o Pure lanolin such as Purlan or Lansinoh may be used. o If pain or soreness continues call your doctor. Breast Pain Your breasts may begin to hurt during nursing or may always be tender or sore. If this happens, it is important to identify the cause. Do not assume breast pain is normal. Engorgement can occur anytime your breasts become full; when your baby misses a feeding or begins to sleep longer at night. Normal let-down sensations can be described as a mild ache, tingling, or “pins and needles” sensation. Infections such as Thrush and Mastitis may cause stabbing, burning or throbbing pain. A deep shooting pain is related to the sudden refilling of the breast. These pains disappear as nursing progresses. Overabundant Milk Some mothers may produce too much milk. You may feel uncomfortably engorged much of the time. Leaking and spraying may be bothersome. Your baby may gasp and choke as the milk lets down. Most women find this is less common after the first two months of nursing. In the meantime, it is best not to interfere with your milk production by taking steps to decrease your supply. Nursing the baby on only one breast per feeding may help. Measures such as decreasing your fluid intake are not recommended. Wearing plastic breast shells or pumping after nursing usually promotes a further increase in milk supply. If your baby has difficulty nursing because the milk lets down forcefully, try nursing the baby as you rest back in a chair to decrease the flow or elevate the baby’s head while feeding. The football hold may also lessen the forcefulness of the flow. BREASTFEEDING YOUR BABY Leaking Milk After a few weeks of nursing you may notice that leaking diminishes or stops entirely. This should not be a cause for concern as long as your baby continues to nurse frequently and continues to gain weight. If continuing leakage becomes bothersome, you can try to stop it by pressing your wrist or heel of your hand against your nipples for a couple of minutes whenever they start to drip. Keep your nipples dry and change breast pads often to prevent sore nipples. If leaking at night continues to be troublesome, you can try nursing just before you go to sleep. Breast Massage Massage promotes effective breast emptying when feeding by helping to release milk from the back of your breast. This can prevent sore nipples, prolonged feeding session and clogged milk duct that result in breast infections. Breast massage should be performed during breast feeding by alternating massage and feeding. Fingertip massage 22 Start at the top of the breast. Press firmly into the chest wall. Move fingers in a circular motion on one spot on the skin. After a few seconds move the fingers to the next area on the breast. Start from the back of the breast and move toward the areola. Gently shake the breast while leaning forward so that gravity will help the let-down reflex. Warm washcloth application Soak a washcloth with warm water; wring. Press washcloth firmly on breast, starting at the back and working toward the areola. Gently shake the breast while leaning forward so that gravity will help the let-down reflex. Diamond hand position Support your breast with both hands, thumbs on top and fingers below. Squeeze your breast gently as you slide your hands forward toward the nipple. Gently shake the breast while leaning forward so that gravity will help the let-down reflex. Parallel hand position Place one hand above and one hand below your breast. Start sliding them toward the nipple. As you slide your hand forward, rotate them. Repeat until you have covered all parts of the breast. Gently shake the breast while leaning forward so that gravity will help the let-down reflex. BREASTFEEDING YOUR BABY How to Massage during Feedings: Put your baby to your breast and observe how he nurses. Usually, after the first minute or so the movements of the baby’s mouth become long, slow and rhythmic. In this type of nursing, your baby compresses the milk reservoirs with his gums and swallows the milk. Such nursing avoids production of sustained negative pressure, which is responsible for injuring the nipple. After a while you notice that your baby stops nursing, then he goes on as before. As the feeding proceeds, he rests more frequently and the character of the nursing changes from mouth movements that are long, slow, and rhythmic to those that are rapid and shallow. Later, there are still fewer slow, rhythmic mouth movements and more of the sleepy, rapid, shallow type. It is the shallow kind of nursing that produces sustained negative 23 pressure that hurts the nipple. Your baby cannot extract milk from the breast when he nurses in this manner. When the pattern of your baby’s nursing changes from long, slow mouth movements to sleeping for the most part or to rapid shallow mouth movements, start alternating breast massage with nursing. Do not remove your baby from your breast; simply slip your hand to the back and middle portion of the breast near the armpit and gently massage the breast several times. While the breast is being moved your baby usually stops nursing, then responds by nursing with long, slow strokes. He may take only two or three sucks, however, because he can quickly pick up the milk that the massage has caused to move from the alveoli to the milk reservoirs. Repeat the massage and permit your baby to nurse again. Often, you will find your breast softening beneath your fingers. When one area softens, move your fingers to a new position and continue alternating breast massage with nursing until the entire breast has been softened. It is important not to use breast massage until the character of the baby’s nursing has changed from long, slow mouth movements to sleeping or to rapid shallow nursing. If massage is used before this time, the milk flows too fast for your baby to manage. 24 Pumping: Breast Pumps All breast pumps use adapters called flanges. Flanges are funnel-shaped devices that fit over your breast and produce a suck-release action when pumping is taking place. They press on the milk reservoirs underneath the areola, pushing out the milk. Properly fitted flanges fit snugly, but allow the nipple to slip easily into the opening. Good fit Flange is too Small You know you have a good flange fit when you can see space around your nipple. The photo above shows a good fit. You can see room around the nipple as it is pulled into the nipple tunnel. If your nipple always rubs along the flange sides, as shown above, it is too tight. A tight fit squeezes the milk ducts and slows milk flow. Rubbing may cause pain, and friction can even break the skin. Pumps may be manually-operated, battery-operated, or electrical. Electrical pumps produce the best pumping action and are most like baby’s natural sucking action. The breast pump you choose will depend on your pumping needs. For occasional use, a manual or mini-electric pump is appropriate. For more frequent pumping, a double electric pump would be helpful. For full-time pumping, a rented, hospital-grade pump is recommended. If you have questions about which type of pump will meet your needs, please contact your lactation consultant or nurse educator. Cylinder pumps Also called syringe or piston-type pumps. Cylinder pumps may be either manual or electric. They’re light-weight and can be very effective. They require both hands for operation. Some women find their hands tire easily when using the manual type. Trigger-handle pumps Suction is created by squeezing a trigger handle. This is a more effective manual pump. 25 Electric pumps Battery-operated pumps Battery-operated pumps require only one hand to use. They have several advantages over plug-in models. They’re more portable and require no electrical outlets. On the other hand, they’re less efficient and batteries need to be replaced frequently. Some battery pumps can be purchased with an AC Adapter. Electric pumps are gentle, efficient and require only one hand operation. These pumps can do double or single pumping. Electric pumps range in size from a small 2pound model to a model the size of a small sewing machine. The large models, which are very expensive, can be rented from some drugstores and medical supply firms. Try to get an electric pump with a suck cycle of 50 to 60 sucks per minute, more like the infant’s suck cycle. If you’re employed by a large company, you might consider sharing the rental fee with other nursing mothers who work there. Each mother should have her own flange and collection containers. Developing and Maintaining a Milk Supply Through Pumping Pumping should be done if your baby is unable to nurse or is nursing ineffectively. Ideally, pumping should begin within a few hours of giving birth. Pumping should be done on a regular schedule, preferably every two or three hours during the day using a double pump. o If using a single pump, a pumping session should consist of: Five to eight minutes of pumping on each side. Massage. Then three to five minutes of pumping on each side. Continue going back and forth until the flow of milk has stopped. You should awaken at least once during the night to pump, especially between midnight and 3 am. You should schedule yourself for at least eight sessions during a 24-hour period, resting in-between. Double pump for 15 minutes or for at least two minutes after the flow of milk has stopped. Breast massage should be done before and during each session to increase prolactin levels to increase your milk supply. You can expect fluctuations in your milk supply. The important thing is to keep the glands functioning, the ducts open, and some milk coming. For many women the supply can be increased by pumping more often. Some women only start to increase the milk supply when their infants begin to nurse. BREASTFEEDING YOUR BABY How to Pump (Single Breast): Wash hands thoroughly. Express in a comfortable setting with privacy and comfortable seating. 26 Relax with a soothing drink for a few minutes. Allow enough time so as to not feel rushed. Begin with a warm compress and massage your breasts. Begin pumping on one side. If little milk is collected, try breast massage. A picture of your baby can often help the let-down reflex and increase milk yield. After five to eight minutes of single pumping on one side, switch to the other side for five to eight minutes, or double pump for 15 minutes. Massage both breasts for a few minutes. Single pump each breast again for three to five minutes. How to Pump (Double Pumping): the preferred method when possible. It requires the least amount of time and increases production levels faster than single pumping. Wash hands thoroughly. Express in a comfortable setting with privacy and comfortable seating. Relax with a soothing drink for a few minutes. Allow enough time so as to not feel rushed. Begin with a warm compress and massage your breasts. Double pump for 10 to 15 minutes or two minutes after the flow of milk has stopped. Storage of Breast Milk Store in plastic bottle bags, rigid plastic bottles or glass containers. Freeze plastic bottle bags in an upright position. Double bag to prevent leaks. Store in 2 to 4 ounce volumes depending on the amount your baby usually takes at each feeding. Smaller amounts thaw quicker and you will waste less. Do not add freshly expressed milk to milk already frozen. This may cause the previously frozen milk to thaw and increases the risk of contamination. You may continue to add small amounts of breast milk to the same container throughout the day. Chill in the refrigerator until evening. Then, freeze in appropriate amounts. Label container with baby’s name, date and amount collected. Thaw by placing the container under warm, running water. Do not use hot water, as this can destroy some of the immunological protection. Shake bottle to ensure an even temperature and to mix any fat that has separated. Test a few drops on your wrist to be sure it is near body temperature. Never use a microwave because it heats the milk unevenly. Temperatures greater than 100° degrees Fahrenheit destroy vitamins contained in the milk. Discard any breast milk left in the bottle after a feeding because bacteria enters from the baby’s mouth and contaminates the milk. If you need to transport milk to the hospital, keep it frozen. Bring refrigerated or frozen milk to the hospital well-packed in ice or reusable freezer packs in an ice chest. If the milk thaws or becomes slushy it should be used within 24 hours. 27 The color, consistency and odor of your breast milk may vary depending upon your diet. BREASTFEEDING YOUR BABY BREAST MILK COLLECTION How much breast milk should you leave for your baby for each feeding? That depends on the individual infant, but here are some guidelines: Average Intake By Age Average Intake By Weight Months Old Ounces per feeding Weight of Infant Ounces in 24 hrs Weight of Infant Ounces per feeding 0-2 2-4 4-6 2-5 oz 4-6 oz 5-6 oz 8 lbs. 9 lbs. 10 lbs. 21.3 oz. 24.0 oz. 26.7 oz. 11 lbs. 12 lbs. 14 lbs. 29.3 oz. 32.0 oz. 37.3 oz. **(Take the Weight of the baby in pounds and multiply it by 2.6. This is how many ounces is needed in 24 hours.) Storage Guidelines: Room Temp. Refrigerator Home Freezer Freshly Expressed 6-10 hrs. 72 hrs. 6 mo. Thawed Breast Do Not Keep at Room temp 24 hrs. Never Refreeze Thawed Milk -20°F Freezer 12 mo. Never Refreeze Thawed Milk BY Expressing Breast Milk By Hand Expressing milk by hand involves one important principle; the milk must be squeezed from the back of the milk reservoirs forward. This means that the squeezing motion begins well behind the areola and moves forward. The final squeeze of your fingers must be just behind the outer edge of the areola and not on the areola or nipple. In this way, the milk stored in the reservoirs is pushed out of the nipple openings. Grasp the outer edge of the areola between thumb and two fingers – thumb on top, fingers below. Squeeze fingers and thumb together while pushing away from the nipple. Change direction and squeeze toward the nipple. Move thumb and fingers a quarter turn and repeat until you have gone all the way around the breast. Techniques of manual expression vary from mother to mother. Each woman develops variations that work best for her. When you’re first learning, practice while you are in the shower or bath feeling relaxed. Try different pressures of your thumb and fingers. 28 Babies With Special Needs Some babies may be born with “special needs.” Conditions such as prematurity, Down Syndrome, a cardiac condition or cleft lip and/or cleft palate may require different breastfeeding techniques. Nursing is still possible, even though a medical condition may be present. In fact, breast milk may be even more advantageous for these infants. Since each situation is different, ask your lactation consultant or Mother/Baby Educator for the personal help you need. Alcohol, Tobacco, Drugs The amount of alcohol that passes into breast milk can vary, but remember, it does pass into the breast milk. There is no way to tell how much alcohol can affect a nursing baby, and therefore alcohol is not recommended for nursing mothers. It is best for a nursing mother not to smoke; it may cause a reduction in your milk production. As with alcohol, nicotine and other potentially harmful substances in cigarettes pass into the milk. Inhaling cigarette smoke can cause potentially serious respiratory problems for your baby. Some recent studies conclude that breast-fed babies of smoking mothers sleep less and cry more. You should never smoke while nursing; besides the risks mentioned above, your baby could be burned. Most medications taken by a nursing mother pass into the milk. The medications prescribed by your doctor while you are a patient in the hospital are perfectly safe to take. Always consult with your doctor or lactation specialist before taking any other medications. Illegal substances, such as marijuana or cocaine, remain in your body for an extended period of time and are passed to your baby when breastfeeding. They should never be used by the breastfeeding mother. If your doctor prescribes a new medication for you, be sure to remind him you are still nursing your baby. If you have to take a medicine that may be harmful to your nursing baby, and if you need to take it for only a short period of time, pump or express your milk and discard it while feeding your baby formula or previously expressed milk. You may resume nursing as soon as the doctor tells you the drug is no longer in your system. 29 Nutrition When you are pregnant, your body stores extra nutrients and fat to prepare you for breastfeeding. Once your baby is born, you need more food and nutrients than normal to provide fuel for milk production. When you are nursing: Eat a well-balanced diet. During breastfeeding you need about 500 calories a day more than you did before you became pregnant or about 2,500 calories a day for most women. Make sure you get 1,000 mg of calcium a day. It is recommended to continue taking a daily vitamin as long as you are breast feeding. Avoid foods that bother the baby. If your baby acts fussy or gets a rash, diarrhea, or congestion after nursing, let your baby's doctor know. This can signal a food allergy. Drink at least eight glasses of liquid a day. Do not drink large amounts of beverages with caffeine, like coffee, teas and colas or alcoholic beverages. Moderation is essential. Fluids Drink 2-3 quarts daily (ex.: water, herb tea, fruit juice) or drink to quench your thirst. Find Your Balance Between Food and Physical Activity Be sure to stay within your daily calorie needs. Do light physical activity at least 30 minutes most days of the week. Know the Limits on Fats, Sugars and Salt (Sodium) Make most of your fat sources from fish, nuts and vegetable oils. Limit solid fats like butter, stick margarine, shortening and lard, as well as foods that contain these. Check the Nutrition Facts label to keep saturated fats, trans fats and sodium low. Choose food and beverages low in added sugars. Added sugars contribute calories with few, if any, nutrients. Make half your grains whole. Vary your veggies. Eat more dark-green veggies like broccoli, spinach and other dark leafy greens. Eat more orange vegetables like carrots and sweet potatoes. Eat more dry beans and peas like pinto beans, kidney beans and lentils. Focus on fruits. Eat a variety of fruit. Choose fresh, frozen, canned or dried fruit. Go easy on fruit juices. 30 Get your calcium-rich foods. • Go low-fat or fat-free when you choose milk, yogurt and other milk products. • If you don’t or can’t consume milk, choose lactose-free products or other calcium sources such as fortified foods and beverages. Go lean with protein. • Choose low-fat or lean meats and poultry. • Bake it, broil it or grill it. • Vary your protein routine - choose more fish, beans, peas, nuts and seeds. 31 Supplemental Feeding It is important to wait to introduce bottle feeding until you and your baby have had at least three to four weeks of successful breastfeeding. This way supplemental feedings won’t interfere with the establishment of your breast milk supply and promote nipple confusion. When you decide to add supplemental feedings there are many ways you can choose to do this. When you are away, your baby can receive a supplemental feeding by bottle. You can pump during a missed feeding or eliminate a feeding completely. Ideally the supplement will be breast milk you have expressed and stored in the refrigerator or freezer. If for any reason breast milk is not available, formula may be used. The amount of formula your baby will need for one occasion can be prepared with powder since any formula left in the bottle or cup needs to be thrown away. Some babies do better if someone other than their mother gives the first several bottles. If you plan to have your baby fed mostly breast milk, start expressing your milk and storing it in the freezer several weeks before your new routine starts. To begin this freezer supply, you may want to express milk after a feeding when your baby hasn’t vigorously nursed. Another good time to express and build your frozen milk supply is when you miss a breastfeeding session in order to give your baby the first supplemental feeding. If you are planning to continue to mostly breastfeed, substitute feedings should be used only when necessary and no more than once or twice a day. If your milk supply seems to be decreasing, continue to express milk frequently while you are away. You may want to increase breastfeeding sessions when at home. This should increase your supply. 32 Weaning From Breastfeeding There is no set time or age to begin weaning your baby. The American Academy of Pediatrics recommends breastfeeding through the first year of life as a minimum. However, you may decide to wean your baby earlier. The decision to discontinue breastfeeding partially or completely can be made by you and your baby at any age. When you have made the choice to begin weaning to a cup or bottle, depending on your infant’s age, do it gradually. Select any one feeding to skip, except the last one in the evening, or the first one in the morning. Instead of nursing, offer a cup or bottle of breast milk, or formula. Your breast may feel full during this time for a couple of days, but soon your body will adjust to deleting this feeding. Wait several days, to a week, before you choose to wean from another feeding; do not choose two consecutive feedings. At some point though, you may have to do this. Eventually, you will be left with just the morning and evening feedings to wean from. At this time, you may choose either one of these, or your baby may make the choice for you. After you have weaned completely, you may at times feel that your breasts are full. This is a very normal sensation. Either nurse your baby just enough to relieve the discomfort, use your breast pump, or hand express the milk. You may continue to have some breast milk for a few days or weeks, which may leak infrequently. Applying pressure against your breast should stop the milk from leaking at that moment. Menses As a breastfeeding mother, you probably will not resume your period right away, as long as you are regularly nursing your baby. As you begin to wean or have completely weaned your baby, expect to start your period within a few weeks. Occasionally, a mother may start her period about four to six weeks after the baby is born. Even though she is nursing, she may continue to have her period, either regularly or irregularly. You can continue to nurse during your period; there is no effect on your milk or your baby. Please discuss contraception with your doctor even if you have not resumed your menses. Postpartum Sexuality As new parents, regaining sexuality may be one of the biggest challenges you face. All couples face common physical and psychological obstacles. Many of these are beyond your control to alleviate. For example: • • • • • Vaginal bleeding for several weeks. Uterine contractions. Fatigue. Engorged breasts and sore nipples. Discomfort from your episiotomy or abdominal incision. 33 After a few weeks the majority of these will have subsided except for fatigue. This can become a major problem in your relationship unless you communicate your feelings and needs to each other. When you finally get into bed at night your only interest may be in sleep, not sex. Compassion and understanding for both partners may help you through this stressful time. Encourage sharing housework, errands and caring for baby without being demanding, but make your feelings known. Breastfeeding will help to burn up calories faster than if you were bottle feeding. You may lose your pregnancy weight sooner and begin to look like yourself again, though you still may not feel that way. Be patient; over time you will regain your interest in sex. Your partner may also begin to feel ignored. He sees all of your attention and energy going toward the baby and he may begin to feel neglected. Remember, keep communicating and try to find a time for just the two of you. Low estrogen levels are associated with breastfeeding and may cause vaginal dryness, tightness and tenderness. If intercourse is painful or uncomfortable for you, more foreplay may help. Try to use a water-based lubricant, such as K-Y Jelly. The hormonal changes that occur during foreplay/intercourse stimulate a let-down in some women. If this bothers you or your partner, try feeding the baby or expressing some milk before having intercourse. Applying pressure to the nipples when the milk begins to let-down will stop the milk flow. Your doctor will tell you when you may resume sexual activity. Contraception When you decide to become sexually active, you will need to use a method of birth control if you do not wish to become pregnant. Generally, spacing between pregnancies is recommended for mother and baby’s health. Discuss this with your doctor. As a breastfeeding mother you can become pregnant, even though you may not have started your period yet. The most common methods breastfeeding women use are: • • • • • Condoms. Intrauterine device (IUD). Sterilization. Progesterone only pill: The Mini-pill Injectable progesterone (Depo-Provera). 34 Breast Feeding Log for the First Week of Life • • • • Circle the hour when your baby nurses. Circle the W when your baby has a wet diaper. Circle the S when your baby has a soiled diaper. During the first week, you will use more diapers each day. Day One 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 Wet Diaper W Black tarry soiled diaper S Day Two 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 Wet Diaper W W Black-green tarry soiled diaper S S Day Three 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 Wet Diaper W W W Green soiled diaper S S S Day Four 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 Wet Diaper W W W W Yellow soiled diaper S S S Day Five 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 Wet Diaper W W W W W Yellow soiled diaper S S S Day Six 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 Wet Diaper W W W W W W Yellow soiled diaper S S S S Day Seven 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 Wet Diaper W W W W W W Yellow soiled diaper S S S S Birth Date: _______________ Time: ____________AM PM Goal (at least) 6 to 8 1 1 6 to 8 2 2 8 to 12 3 2 8 to 12 4 3 8 to 12 5 3 8 to 12 6 4 8 to 12 6 to 8+ 4 to 12
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