Be sure that you check and change membranes and tubing as needed and have properly fitting flanges.  Your nipples should fit well into the flanges with just a little space between your nipple and the flange.  Your nipples should not rub in the flanges.  Your nipples should also not bobble about in the flange.   This would indicate that the flanges are too large.  You may want to experiment with flange sizes to find which remove the most milk.  Some moms have better success with alternative type flanges such as Pump in Pals.

Before begining to pump try these techniques

-Massage your breasts in concentric circles as when doing a breast self exam.

-Draw the backs of your fingers or a comb across your breasts from the chest wall to the nipple all around your breast.

-Lean forward and shake your breasts.

Use reverse pressure softening (developed by K. Jean Cotterman RNC-E, IBCLC) until you see drops of milk, then apply the pump.

Use hands-on double pumping. Whenever milk flow slows, take the pump off and repeat everthing including the reverse pressure softening and re-apply the pump. Try to do this cycle three times.

Hands on pumping:

http://newborns.stanford.edu/Breastfeeding/MaxProduction.html

Reverse pressure softening (developed by K. Jean Cotterman RNC-E, IBCLC):

http://www.youtube.com/user/IBCToronto?feature=mhee

If you only have single pumping capacity, just switch back and forth a few times using all the techniques in this article.  If you do not have a pump, use these techniques and then hand express.

http://newborns.stanford.edu/Breastfeeding/HandExpression.html

http://ammehjelpen.no/handmelking?id=907  (video created by the Norwegian mother to mother breastfeeding support organization, Ammehjelpen–scroll down for English video)

In order to have an excellent milk supply, it is important to remove milk from the breasts at least 8-10 times a day. (http://feedthebabyllc.com/care-plan-for-milk-supply/)  When mom and baby are together, it is beneficial to keep baby skin-to-skin and allow free access to the breast.  A baby is better at maintaining a milk supply than a pump and the extra nursing stimulates mom’s breasts to make more milk.

When mom is separated from baby, it is important to express milk as frequently as possible, at least every 3 hours from the beginning of one expression to the beginning of the next.  A double electric pump with properly fitting flanges works the best.  Be sure to check the membranes frequently and change them at least every 3 months.  A pump that is older than 1 year may not be as efficient.  See (http://newborns.stanford.edu/Breastfeeding/MaxProduction.html) for learning a technique that increases the amount of milk that can be expressed by 48%!

Breastfed babies need approximately 25 ounces of breastmilk a day and usually feed 8-10 times in 24 hours.  Two to four ounces per feed is typical.  If the baby is given more milk in bottles than he/she typically receives at the breast, it will be more difficult for the mother to keep up with milk expression during separation.  Small, frequent feeds are also more physiologically appropriate than larger, less frequent feeds.  It can take up to 20 minutes for a baby to realize that he/she is full and bottle-fed babies are frequently overfed.

It is best for mom’s milk supply, if as much milk as possible, comes from direct breastfeeding.  If baby sees the bottle as providing just barely enough and mom’s breasts as the place where milk is plentiful, baby will be more likely to continue to breastfeed and mom will maintain her supply.  Bottle-feeding the breastfed baby involves using techniques that support breastfeeding.  Towards this end, it is ideal to use a slow flow bottle nipple, paced feeds, and to only offer 1-1.5 ounces for every hour mom is separated from baby.  If baby can be fed at drop-off and pick-up, then even less milk will be needed to be fed by bottle.  The following link describes paced bottle-feeding and has hand-outs for care providers. (http://kellymom.com/bf/pumpingmoms/feeding-tools/bottle-feeding/)

Feeding baby at night also helps to keep a milk supply plentiful.  If baby is sleeping thorough the night the breastfeeding mother misses out on some very important stimulation to her milk supply.  If a mom sleeps with her baby, nursing at night can be as simple as rolling over, offering the breast, and going back to sleep.  Many moms are concerned about the safety of sleeping with baby, but research shows it can be made to be just as safe as any other sleep location. (http://www.uppitysciencechick.com/sleep.html) If a mom does not want to sleep with her baby, it is still possible to feed baby a few times at night and just put baby back in his/her own sleep space.  Be sure to not feed baby on a chair or couch.  This is a very unsafe place to fall asleep with a baby.

Many moms, who are separated from their babies during the week, find that their supply is lower by the end of the week.  They often make up for their lowered supply by feeding more frequently on the weekends.  If you find your supply is lowering, try a “nursing holiday” during which you spend all weekend in bed or lying around just nursing.  Keep baby skin-to-skin and nurse all day and all night long.  This will work quickly to increase supply.

©2013 Laura Spitzfaden, LLLL, IBCLC

I had already been an active La Leche League volunteer leader for nearly 14 years when I decided that I wanted to extend my services to include professional breastfeeding support.  I knew that I had acquired a lot of the experience and knowledge needed through my volunteer work.  I had dedicated thousands of hours to learning about and supporting breastfeeding.  I had helped several hundred moms overcome breastfeeding difficulties and realize their breastfeeding goals.  I did not believe, however, that this was adequate training to provide professional breastfeeding services.

Most moms do not need professional breastfeeding support.  Their needs can be filled with the help of knowledgeable volunteers such as La Leche League leaders, WIC peer counselors, certified lactation counselors, Breastfeeding USA counselors and other experienced breastfeeding moms.  Midwives, doulas, physicians and nurses can also provide valuable breastfeeding assistance while working in their capacity as health care providers.  All of these breastfeeding supporters can help moms initiate and continue a breastfeeding relationship in the normal course of uncomplicated breastfeeding, but I believe that moms, who want professional breastfeeding support, deserve nothing less than the expertise of the IBCLC.

Small problems can mask larger issues and can become breastfeeding obstacles if they are mismanaged.  If a mom is ready to take the step of hiring professional breastfeeding help, she needs her provider to have a comprehensive understanding of normal lactation and the extensive clinical experience needed to recognize when a breastfeeding issue deviates from the many variations of normal.  Anything less can undermine the success of a breastfeeding relationship.

As I began working toward my required hours of lactation specific education, I realized how much I still had to learn about helping moms to breastfeed under difficult circumstances.  Earning the IBCLC credential was expensive and time consuming but I knew that it ensured an excellent quality of breastfeeding support.  There are many programs that can provide breastfeeding education but only the IBCLC credential ensures a minimum of educational and clinical hours while also requiring continued education to maintain.  Candidates currently must have 90 hours of lactation specific education and 1000 hours of supervised clinical experience to even be qualified to sit for the exam.  IBCLCs recertify every 5 years through 75 hours of approved continuing education and every 10 years by repeated examination.  This is an expense that ranges from $470-$1000+ every 5 years.

IBCLCs must follow a code of professional conduct and stay within their scope of practice.  IBCLCs have and maintain clinical competencies in maternal and infant anatomy, physiology, endocrinology, nutrition, biochemistry and immunology.  They must have knowledge of infectious disease, pathology, pharmacology, toxicology, psychology, sociology, anthropology, and public health.  They must also have an understanding of ethical and legal issues and the ability to interpret research as well as having knowledge of infant growth parameters, child development, and how to use breastfeeding equipment, technology and techniques.  An IBCLC is an allied health care professional who must obtain consent to treat, follow HIPAA guidelines and provide comprehensive reports to families’ health care providers.  All of these requirements ensure that the IBCLC has the skills to help moms and babies have the best possible opportunity to meet their breastfeeding goals.  This makes the IBCLC the gold standard in lactation support.  Nothing less would satisfy my desire to provide the best possible care for moms and babies.

I am glad that I chose this path.  Acquiring the IBCLC certification taught me how much I still need to learn in order to best serve breastfeeding moms and babies.  Maintaining my certification encourages me to continue to strive for excellence.

©2013 Laura Spitzfaden, LLLL, IBCLC

http://massbreastfeeding.org/landscape/guide/index.html

Image credit: Qole Pejorian on Flickr

This photograph  shows a very obvious tongue-tie and visible frenulum (the bit of tissue holding down the tongue) but not all restrictions are this obvious. Some restrictive frenulums attach further back on the tongue. Some are even buried under the floor of the mouth, causing the tongue to appear, “short.” The only visible indication may be that the floor of the mouth rises when baby lifts his tongue or the tongue stays flat or doesn’t rise to the palate when baby cries. Sometimes the sides of the tongue will rise but the center of the tongue will stay on the floor of the mouth. Even if a baby can reach his or her tongue past the gums or lips, there may still be a tight frenulum restricting baby’s ability to breastfeed effectively.

Ultrasound studies have shown that the tongue movements used by tongue-tied babies are qualitatively different from those used by by babies who are not tongue-tied. These movements are not as effective at removing milk from the breast and can cause significant pain and nipple damage for mom.  In these studies, tongue-tied babies also did not draw the nipple as deeply into the mouth as babies who were not tongue-tied.

Some babies with tongue and/or lip-tie may manage to nurse well enough to gain weight adequately in the early weeks, but they may not be able to maintain a full milk supply as they grow.  Their restrictions will likely continue to affect the ease of breastfeeding.  Feeds may be long and frequent–10-12 times a day or more.  Often these babies do not nurse for comfort and may have difficulty managing solids when they are older.

Tongue and lip-ties affect more than breastfeeding.  Even if a baby can breastfeed well and without causing mom to feel pain, restrictive frenulums can affect jaw and dental development, breathing, chewing, swallowing and digestion.  Tongue and/or lip ties are also associated with reflux, which can cause significant pain for baby and may result in the need for medication.

Any of the following symptoms in mom or baby may indicate that tongue-tie is affecting breastfeeding.

Signs in mom:
•nipple pain and/or erosions
•nipple looks pinched, creased, bruised, or abraded after feeds
•white stripe at the end of the nipple
•painful breasts/vasospasm
•low milk supply
•plugged ducts
•mastitis
•recurring thrush
•frustration, disappointment, and discouragement with breastfeeding
•weaning before mom is ready

Signs in baby:
•poor latch and suck
•unusually strong suck due to baby using excess vacuum to remove milk
•clicking sound while nursing (poor suction)
•ineffective milk transfer
•infrequent swallowing after initial let-down
•inadequate weight gain or weight loss
•irritability or colic
•gas and reflux
•fussiness and frequent arching away from the breast
•fatigue within one to two minutes of beginning to nurse
•difficulty establishing suction to maintain a deep grasp on the breast
•breast tissue sliding in and out of baby’s mouth while feeding
•gradual sliding off the breast
•chewing or biting on the nipple
•falling asleep at the breast without taking in a full feed
•coughing, choking, gulping, or squeaking when feeding
•spilling milk during feeds
•jaw quivering after or between feeds

Assessing baby for tongue-tie: (baby may not have every sign)
•Does baby’s tongue rise less than half-way to the palate when crying?
•Do the sides of the tongue lift but not the center?
•Can you see a dip in the tongue in the center of the mouth?
•Does tongue have a heart shaped tip?
•Does baby have a high, narrow or bubble palate?
•Can you see or feel a tight frenulum?

To feel for a restrictive frenulum, you can use the “Murphy Maneuver,” developed by San-Diego pediatrician Dr. James Murphy. Put your little finger at the base of baby’s tongue and draw across the floor of the mouth. If you feel a resistance in the center of baby’s mouth, that is the frenulum. If you cannot get past this frenulum without going around it, then it may be restrictive enough to affect baby’s ability to breastfeed.

The following link shows a method for visualizing a restrictive frenulum that is difficult to see.

http://www.youtube.com/watch?v=5opSbXvL7yQ

Lip-ties often accompany tongue-ties. If you lift your baby’s upper lip and see a frenulum that is tight and if the gums blanch (turn white) when the lip is lifted, your baby may have a lip-tie. The following two articles may help with assessing for lip-ties.

http://thefunnyshapedwoman.blogspot.com/2011/03/introducing-maxillary-labial-frenulum.html

http://www.kiddsteeth.com/maxillaryfrenum_and_nursingfinal.pdf

What Can You Do?

Cranio Sacral Therapy is a helpful intervention for babies with restrictive frenulums.  CST is a light touch therapy that releases tight muscles and can improve baby’s ability to latch and breastfeed, but CST may need to be repeated frequently order to maintain its effectiveness. There are exercises that might help a baby to compensate for the restrictions and careful attention to latch and positioning, may also help the baby to breastfeed more effectively.  None of these interventions enable the tongue-tied baby to have full mobility of the tongue and they are most effective when used along with release of restrictive frenulums, in order to normalize function.  This procedure is performed with surgical scissors or laser and is called a frenotomy.

Many babies with restrictive frenulums cannot nurse effectively unless both tongue and lip-ties are revised by frenotomy.  With an experienced provider, revision is quick and discomfort is minimal.  The discomfort from a frenotomy varies from unnoticeable (some infants sleep through the procedure) to about the same amount of pain as a from a vaccination.  The baby can nurse immediately afterward which also relieves pain.

If breastfeeding hurts mom or if baby struggles to get enough milk, then the breastfeeding relationship is at risk.  The risks of not breastfeeding outweigh the temporary discomfort of revision.  If you are considering a tongue and/or lip-tie revision, it is important to find a provider who is very experienced in revising restrictive frenulums in infants and who is very familiar with how these restrictive frenulums affect breastfeeding. Experienced providers will know how to revise completely and without the need for general anesthesia.

The following is a link to a video of laser tongue-tie revision in a 14 year old. The doctor has made this available for anyone to view. The mom wanted to have this procedure done because her daughter had jaw tension, clenching and tooth grinding. She also breastfed poorly as an infant.
http://www.youtube.com/watch?v=OmyksitDV70&feature=player_embedded

For more information, visit the following links:

lactationkotlowTTnursingbookaugfc2011-1

http://thefunnyshapedwoman.blogspot.com/2011/03/introducing-maxillary-labial-frenulum.html

http://www.kiddsteeth.com/maxillaryfrenum_and_nursingfinal.pdf

http://kiddsteeth.com/articles.html

www.lunalactation.com/KnoxTT.pdf

American Academy of Pediatrics–Tongue-Tie

http://www.brianpalmerdds.com/

http://www.ncbi.nlm.nih.gov/pubmed/12415069

http://www.llli.org/llleaderweb/lv/lvaprmay02p27.html

http://lowmilksupply.org/tonguetie.shtml

http://breastfeeding.blog.motherwear.com/2011/01/guest-post-shannon-on-posterior-tongue-tie.html

kiddsteeth.com/articles/aerophagia_2011.pdf

http://www.tonguetie.net/

© 2012 Laura Spitzfaden, IBCLC (www.feedthebabyllc.com) laura@feedthebabyllc.com

The following is posted with permission from http://www.drmomma.org/

Breastfeeding Latch Trick

By Danelle Frisbie © 2010

Nipple Twist Latch Steps:

1) Pinch the areola right next to your nipple so the nipple can be moved (it may take a second for the nipple to evert if it was otherwise flat). You can use your thumb and first finger, or 2 fingers – whichever is easier for that side and the shape of your breasts. If you have ‘puffy’ breasts, you can also position the rest of your hand under your breast to lift it up slightly and away from your chest.

2) Turn the nipple up so it is pointing at your face. Do not be shocked if some milk exits. This is normal as you are putting very slight pressure on the milk ducts. There is no need to wipe off the milk as the scent will only help to encourage baby to nurse.

3) Position baby’s mouth at the bottom of your upturned nipple, so baby’s mouth is open over your nipple/finger and onto the above areola.

4) When you let go, the nipple will land deep into baby’s mouth – where it is meant to be for comfortable latch and sucking.

Scroll down to the bottom of the link to view a video showing how to use this technique.

http://www.drmomma.org/2010/08/breastfeeding-latch-trick.html

http://www.ambermccann.com/blog/milksharing/

Like Amber, I am an International Board Certified Lactation Consultant.  I am also a La Leche League Leader.  La Leche League’s position on milk-sharing discourages leaders from providing moms with information about informal milk-sharing unless the mother specifically requests such information.  If mothers ask a LLL Leader how to obtain human milk supplements for their babies, they must be directed to milk banks, even though the cost of purchasing human milk from a milk bank is prohibitive.  In most cases, there is not enough milk available for the ill or preterm babies who need it, let alone any excess available for purchase for healthy babies.  This is simply not a viable option for most families.

Avoiding the topic of informal milk-sharing does not take into account the changing social environment of the moms we serve.  Through social media and the internet, mothers are more informed than ever about the risks of artificial feeding and about what their babies are missing if they do not breastfeed.  Over the last few years, I have observed that informal milk-sharing has rapidly become commonplace.  I am witness to many instances of mothers offering their milk to other mothers who need or want supplemental milk.  Mothers are sharing their milk whether or not any organization believes it is safe.

While there are risks involved with informally sharing breastmilk due to the potential to spread illness or to expose infants to drugs or chemicals, those risks can be mitigated.  It seems disingenuous to be concerned about contamination of breastmilk, when it is well documented that artificial feeding carries significant risks for babies and that formula is often found to be contaminated with chemicals and pathogens.

One risk of informal milk-sharing that I have not seen addressed is that accepting donations of milk from another mother, may put a mother’s own milk supply at risk.  Often a mother believes she does not have enough milk or that there is something inadequate about her milk and believes she needs to supplement.  If it is simple to get milk from another mother, and she doesn’t have access to information about all the risks and benefits of supplementation, she may not explore the reasons for her own supply issues or discover there is no problem with her milk supply.  She may supplement unecessarily and unintentionally reduce the amount of her own milk that is available to her baby.   If providing information about informal milk-sharing is discouraged, and focus is placed on the risk of possible contamination, the more significant risk to a mother’s milk supply is potentially overlooked.

Research into mother and infant sleep practices by Kathleen Kendall-Tackett, P.h.D., IBCLC, RLC, has shown that dictating to mothers what they should and shouldn’t do, doesn’t work.  Telling mothers that they shouldn’t sleep with their babies in adult beds, only results in mothers falling asleep with their babies in even less safe environments, or ignoring the advice while being deprived of the information needed to make bed-sharing safer.  Just as many breastfeeding advocates support mothers in bed-sharing with their babies, due to the belief that bed-sharing benefits breastfeeding, and its practice can be made safer, we can also support human milk sharing by providing moms with the information they need to make informal milk-sharing safer.  I believe it is time for child health advocates to stop telling moms what to do and instead, provide all the information that moms need in order to make their own informed choices about milk-sharing.

While it is not possible to make any infant feeding option risk-free, mothers can be provided with the information they need to evaluate and minimize the risks and make their own informed decisions.  The World Health Organization offers a heirarchy for infant feeding if a baby cannot be breastfed by his or her mother, “..expressed breast milk from an infant’s own mother, breast milk from a healthy wet-nurse or a human-milk bank, or a breastmilk substitute…” in that order.  It is up to infant health advocates to help mothers to be informed of the risks and benefits of each option, so they may choose for their own babies.

Laura Spitzfaden, LLLL, IBCLC

In March 2011, the LLLI Board of Directors adopted the following policy regarding the donation of human milk: http://www.llli.org/release/milksharing.html

Mother-Infant Sleep Locations and Nighttime Feeding: U.S. Data from the Survey of Mothers’ Sleep and Fatigue-Kathleen Kendall-Tackett Ph.D., IBCLC, RLC et.al.

Updated to add some links to peer-to-peer milk sharing research papers:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3395287/

http://bfnews.blogspot.com/2012/09/dr-karleen-gribble-biomedical-ethics.html

 http://media.clinicallactation.org/4-1/CL4-1Wilson-Clay.pdf

This class is an ongoing event that occurs on the first Saturday and third Tuesday of each month.   The triage/clinic is available on Saturday, only. Please register at least 3 days in advance to ensure that the class will not be cancelled.  Late registrations may be accepted if space is available.

Saturday class is 10am-12pm.  Saturday Triage/Clinic is held between 12:00pm-2pm.  Tuesday class is from 6pm-8pm.

The Saturday class will address common difficulties such as how to prevent and treat sore nipples, how to achieve a comfortable latch,  how to avoid and treat thrush and mastitis, how to relieve edema using reverse pressure softening (a technique developed by K. Jean Cotterman RNC-E, IBCLC), how to know if baby is feeding well and how to increase a suppressed milk supply.  Class size is limited to 15 adults, including partners (partners attend free).  Please bring a soft bodied doll or stuffed toy to class.

The Triage/Clinic is for moms and their nursing babies.  It is designed to help moms who are having breastfeeding difficulties and who would benefit from the services of an IBCLC, but who do not wish to schedule a home-visit.  If the difficulties cannot be fully addressed by this clinic, a mom may apply the cost of the clinic to a full lactation consult home-visit.  Clinic size is limited to 2 nursing dyads.  This clinic includes assembling a full lactation history, a pre and post-feed weighing to determine intake, an observation of feeding and an infant oral exam.  You will be provided with a breastfeeding care-plan and a physician report.  Attendees must arrive 30 minutes before the clinic to fill out a history and consent form.  This is critical because there will be no time during the clinic for paperwork and the clinic cannot begin before paperwork is completed.

The Tuesday class is a “getting started with breastfeeding” class and covers topics such as, breastfeeding friendly labor and birth practices, latch and positioning techniques, hand expression, normal newborn feeding behaviors, managing engorgement, how to know your baby is transferring milk and troubleshooting difficulties.  I will also provide information on choosing a breast pump, though not every mom needs a pump!  Please bring a soft bodied doll or stuffed toy to class.

Saturday and Tuesday Class fee 35.00

Triage/Clinic fee 70.00

Breastfeeding Class and Triage/Clinic combination is 80.00 (only 70.00 may be applied toward a home-visit if needed)

Contact Laura Spitzfaden at 517-285-7819 or laura@feedthebabyllc.com to register.

Breastfeeding Videos

Learn to hand-express colostrum. This milk is already in your breast and will be your baby’s first food.  If your baby has any difficulty latching in the first few days, you can hand express this colostrum and feed the baby by spoon.  Moms with gestational diabetes may even consider expressing and freezing some colostrum while pregnant, in case supplementation is indicated after birth.  Do not use this frozen colostrum as a replacement for feeding at the breast!  It is important to future milk supply that colostrum is removed in the first few days after birth, by breastfeeding or by hand expression.

http://newborns.stanford.edu/Breastfeeding/HandExpression.html

http://ammehjelpen.no/handmelking?id=907

Birth

Immediate skin-to-skin contact with baby on mom’s chest is best for mom and baby and their breastfeeding relationship.  Remain in skin-to-skin contact, as much as possible, until your baby is breastfeeding easily.  Skin-to-skin contact promotes stable temperature, heart rate, breathing and blood sugar.  This allows your baby to be in the most receptive state for learning to breastfeed.  Babies in skin-to-skin contact with mom are more likely to latch and breastfeed well, right from the start.

Immediate skin-to-skin contact after birth also helps to properly colonize baby with mom’s bacteria.  Babies are born with a sterile gut and they become colonized with the bacteria they contact in mom’s birth canal and mom’s skin.  Babies who are born by cesarean have not come into contact with the bacteria in the birth canal and are especially vulnerable to being colonized with hospital bacteria.  Colonizing baby with mom’s bacteria, may also protect mom from being infected with hospital bacteria in her breasts and nipples.

Do not allow anyone to put anything into baby’s mouth unless medically necessary. Suctioning should be avoided if possible.  Ideally, baby’s first oral experience is to latch and breastfeed.

Delay routine procedures until baby has latched and breastfed or for at least the first hour. If your baby is healthy, there is no medical reason to separate mom and baby for routine procedures.  Baby’s temperature stabilizes best on mom’s chest and breastfeeding is facilitated by protecting this critical first hour.  Even after cesarean birth, baby can be immediately placed on mom’s chest.

Day 1

Stay in skin-to-skin contact, do not swaddle baby.  Swaddled babies do not stay as warm as babies in skin-to-skin contact with mom and they do not breastfeed as well or as frequently.  Babies use their hands to help them find the breast and to stimulate the breast and nipple to release milk.  Swaddling deprives babies of the use of their hands and inhibits many other inborn feeding reflexes.

Use a laid-back breastfeeding position. http://www.biologicalnurturing.com/  This position involves lying back comfortably, well supported by pillows, while allowing baby to lie against your body, with his head just above and between your breasts.  Gravity and contact with your body stimulates baby’s inborn feeding reflexes and allows him to find his own way to the breast.  Talk to your baby, stroke him and make eye contact.  Soon he will begin to bob his head and try to move down toward your breast.  Help your baby to do what he is trying to do but let him take the lead.  Baby may use his hands to help find the breast and may suck on his fist to calm himself along the way.  If you or baby get frustrated, just bring baby back to the position in which he is upright between your breasts and let him begin again.  Laid-back breastfeeding allows both you and your baby to rely on instinct rather than following prescribed steps for latching.

Feed baby as frequently as baby is willing, even if baby is half asleep. Newborns need to nurse 10-12 times a day or more to properly stimulate a good milk supply and to learn to breastfeed well.  Watch for feeding cues: rooting, squirming, rapid eye movements, head turning, hand to mouth movements, small sounds or sighs.  These cues mean baby is ready to feed.  Crying is a very late feeding cue and crying babies are difficult to breastfeed.

Begin hand-expression and spoon feeding by 6 hours if baby is not latching or not transferring milk.  If you are unsure that baby is feeding well, it is best to express some colostrum after feeds and give it to baby.  You will be able to express a few drops to a few teaspoonfuls in the first 3 days after birth.  On the first day, babies who are breastfeeding well, transfer between 2-10 ml per feed with 8-12 feeds per day, averaging 45ml total transfer for the first day.  If baby is not latching, hand-express at least 8 times a day and feed baby by spoon or cup. Do not use a breast pump until milk increases.  Breast pumps are not especially effective at removing colostrum and the vacuum can increase edema in the areola, slowing or stalling milk transfer.

If your areolas feel firm, use reverse pressure softening RPS* (developed by K. Jean Cotterman RNC-E, IBCLC). Especially if you have had any IV fluids or pitocin, you may experience edema (retained fluid) in your breast.  This can cause pressure on milk ducts and slow or stop the transfer of milk.  Milk that sits in your breast signals the breast to slow down production so it is very important to relieve edema.  Reverse pressure softening moves this retained fluid back into the breast, allowing it to drain through the lymph system.   RPS also stimulates the nerves in the breast that signal milk to “let down” and will help get milk flowing for feeding or hand-expression..

Do not use a nipple shield!  Nipple shields can be useful tools for some breastfeeding difficulties, but they are not helpful in the first few days before the milk supply has increased.  Colostrum is much thicker than mature milk and is not easy to transfer with a nipple shield.  The shield also provides a firm sensation in baby’s mouth that is not similar to mom’s nipple.  It is better to hand express and spoon feed until baby learns to latch onto the breast.

If your nipples are flat or inverted, your baby may, but not necessarily, have difficulty latching at first.  If your baby is having difficulty latching, due to flat or inverted nipples, avoid putting your finger, a pacifier or a bottle nipple into baby’s mouth.  Do not bottle-feed or finger-feed.  Hand express colostrum and feed with a spoon or cup.  Stay in skin-to-skin contact and ask for help with techniques that can assist baby with latching.

Breastfeeding should not be painful.  If you are experiencing any pain, ask for help with baby’s latch and positioning.  Laid-back positioning usually results in a comfortable latch but you may need extra help.  Baby should release your nipple in a regular round shape with no pinching or discoloration.  If nipple is being pinched, feeding will be painful and nipple tissue may break down and crack.

If baby is not latching or breastfeeding is painful check baby for tongue and lip-tie.  This is a common reason for latching and milk transfer difficulties.  A simple procedure, called a frenotomy can be performed to help baby breastfeed more comfortably.

Baby should have at least 1 wet diaper and 1 bowel movement on day 1.

Day 2

Remain in skin-to-skin contact.  Expect to feed baby 8-12 times a day or more.  Your colostrum is available in small amounts, just right for baby’s tiny stomach.  Baby must feed frequently in order to properly stimulate a full milk supply.  On day two, babies who are breastfeeding well typically feed 8-12 times and transfer 5-15 ml per feed.

Baby’s weight loss over the first 24 hours may be influenced by IV fluids. If your baby has lost more than 7% of birth-weight at this time, it is likely that baby was over-hydrated at birth due to IV fluids given to mom.  This may be especially pronounced if mom was given 2L or more IV fluids.  This weight loss is not a reason to supplement with formula.  Continue to breastfeed or to hand-express colostrum and spoon-feed.

Baby should have 2 wet diapers and 3 bowel movements on day 2.

Day 3

Sometime on day 3 or 4, your breasts will begin to feel fuller. There has been milk in your breasts even before birth, but the birth of the placenta sends a signal for milk supply to rapidly increase.  The composition of the milk will change and begin to look more watery.  Most moms notice this increase around the third or fourth day.  Moms with gestational diabetes or who have had c-sections may experience a delay, of up to a day, before their milk increases.  Milk intake on day 3 will be approximately 15-30 ml per feed resulting in approximately 300ml over 10 feeds.

If baby is not directly breastfeeding, switch from hand-expression to expressing with a hospital grade double electric pump and use hands-on-pumping technique.   http://newborns.stanford.edu/Breastfeeding/MaxProduction.html  Express milk at least 120 minutes every day.  Express approximately 8-10 times a day for 15-20 minutes.  If milk volume has not yet increased, continue to hand-express in addition to electric pumping.

Skin-to-skin contact is still important.  It is especially important for the baby who is not latching but it is helpful for all babies while learning to breastfeed.

Lying back helps baby to latch more easily and to control increasing milk flow.  Many babies have difficulty adjusting to the increasing volume of breastmilk and laid-back breastfeeding helps them to have control over the flow of milk.

Avoid bottles if baby is not breastfeeding well.  Bottles require different tongue and jaw movements than breastfeeding and may make it more difficult for baby to learn to breastfeed.  Cup-feeding or finger feeding are options for feeding baby.

Baby should have 3 wet diapers and 3 bowel movements on day 3.

Day 4

Mom may be experiencing some engorgement.  Breasts may feel very firm and lumpy.  Frequent nursing, until breasts soften, can reduce the likelihood of engorgement.  If engorgement becomes uncomfortable or painful, cold compresses and ibuprofen may reduce inflammation.  Baby may have difficulty nursing from a breast when it is engorged due to firmness in the areola.  Use reverse pressure softening before breastfeeding or pumping to move edema out of the areolas and make them more soft.  Unrelieved engorgement may reduce milk supply so do not allow milk to sit in the breast.

If breastfeeding is going well, baby will have 6 very wet diapers and 3-5 bowel movements.  Bowel movements should begin changing to yellow and seedy by day 4 or 5.  Baby will be taking approximately 400 ml on day 4.

Day 5

Watch for signs that baby is getting enough milk.  Baby should lose no more than 7% of birth-weight, though some babies lose more due to over-hydration at birth if mom received IV fluids.  Baby should begin to gain 2/3-1 ounce a day starting on day 5 and regain birth-weight by 10 days to two weeks.

Watch for swallowing.  When baby latches, the first sucks will be quick and there may be several pauses.  When milk “lets down” baby’s rate of suckling should quickly become steady and slow to one suck per second.  When baby swallows, you will see baby’s jaw drop slightly every 1-2 sucks.  Baby should have a pattern of 10-20 swallows before taking a short 3-5 second break.  Baby should be spending most of a 15-30 minute feed actively sucking and swallowing.  If sucking is fluttery and quicker than 1 suck per second, baby is not transferring much milk.  Your breast should soften and baby should release the breast and seem satisfied.

Some newborns feed more quickly.  If your baby nurses for 10 minutes or less but is actively swallowing for the full feed, he may be getting plenty of milk.  However, the baby who swallows for just a few minutes and then falls asleep may not be getting enough.

Watch diapers.  Baby should have 6 wet diapers and 4 yellow bowel movements, at least the size of a quarter, every day after the 4th day of life.  Baby will transfer an average of 500ml on day 5.

Day 5-2weeks

You may still experience edema for up to two weeks.  Continue to use RPS to soften areolas if they feel firm.  If your breasts are pendulous, edema will collect in your areolas, so it is a good idea to recline, when using RPS.

Milk intake will continue to increase for the first few weeks until baby is taking approximately 750 mls or 25 ounces every day.   Babies usually consume 2-2.5 ounces of breastmilk per pound of body-weight, per day, until they reach an average intake of 25 ounces per day.  This intake is stable from 1 month until around 6 months.

If baby is not latching, or if you are having pain or low milk supply, consider hiring a Board Certified Lactation Consultant.  IBCLCs are the gold standard in lactation support and will help you overcome your breastfeeding difficulties.  You can also get help from La Leche League.  La Leche League Leaders are available by phone to answer questions and help you solve breastfeeding difficulties.

* See reverse pressure softening handout, developed by K. Jean Cotterman, RNC-E, IBCLC (mellomom@gmail.com)

© 2012 Laura Spitzfaden, LLLL, IBCLC