A Soft Place to Land

Today is IBCLC Day. As an International Board Certified Lactation Consultant, this has a lot of meaning for me. I am remembering all the families I have supported and feeling warm and fuzzy and proud. I scroll through Facebook and see fellow IBCLCs posting positive messages about our profession. I love my job! I love breastfeeding! Human milk is so much more than nutrition. I want all the babies to have it. I am reflecting on ways I can improve my care of families and parents who want to provide human milk for their infants and….wait!

On my Facebook news feed, I saw that a friend has shared a new message (just in time for IBCLC Day) from an organization that works to directly undermine breastfeeding. My first reaction was to feel angry and frustrated. Why can’t my friends see that this organization is wrong and I am right? I wanted to rush in and share all the reasons why they should not provide a signal boost for this organization.

And then I decided to sit with it and step back a little. The real questions are: Why does this organization own the message that exclusive breastfeeding does not always work? What are breastfeeding supporters doing to push parents into the arms of this organization? FIB is providing a soft space to land for those parents who did not receive adequate breastfeeding support. How can we do better?

We need to understand that parents already know that breastfeeding is important for their health and the health of their infants. “Of the approximately 4 million babies born in 2015, most (83.2 percent) started out breastfeeding – but many stop earlier than recommended…”- CDC Releases 2018 Breastfeeding Report Card If 83.2% of US parents are initiating breastfeeding, the message that breastfeeding is critical for infant and parent health is getting through loud and clear. However, without adequate support, this message also serves to create stress and anxiety in parents who do not reach their own breastfeeding goals.

Exclusive breastfeeding for the first 6 months of an infant’s life is a very important universal health goal. In trying to promote this message in a society that does not support parents, we are placing parents between a rock and a hard place. No wonder they are running from our message. Parents who find themselves unable to exclusively breastfeed or to breastfeed at all, feel as if they are failing. But parents do not fail at breastfeeding. We are failing parents.

New parents are sent home from U.S. hospitals with no idea how to tell if their infant is breastfeeding well and no idea of when or how to appropriately supplement their infant if needed. “Fed is Best” steps in to fill this vacuum but they are not a friend to parents. They are a predatory organization that is exploiting parent and health care provider’s fears in order to undermine policies that support exclusive breastfeeding. They have shown by their lack of cooperation with recognized health organizations that they do not care about infant well-being.

In order to get the most human milk into the most human babies, the focus must shift from promotion to support. While breastfeeding is “natural” it isn’t usually easy. Most parents struggle somewhat in initiating breastfeeding. Some struggle more than others. Some experience severe pain and physical and emotional trauma. Some do not make enough milk to completely sustain their infants and we need to acknowledge that without undermining each parent’s potential to exclusively breastfeed.

Lactation is a robust system but it can be compromised. Just like any other organ in the body, the breasts can fail to work optimally for so many different reasons, including reasons outside the control of the parent. Most of the time, with excellent support, a parent can exclusively breastfeed if they choose to do so, but many of them do not get this support. If they are fortunate enough to initiate exclusive breastfeeding, most will still struggle to continue to provide breastmilk to their infants if they must return to employment outside their homes.

The United States fails parents and children with a lack of universal health care and with profoundly, criminally, inadequate parental leave policies. Parents need high quality, timely breastfeeding support that they can afford in order to reach their own breastfeeding goals. They need universal health care that pays for this high quality breastfeeding support. They need paid leave in order to spend uninterrupted time with their newborns and young children in order to establish and maintain breastfeeding for as long as they choose.

We need to provide more families with the services of the highly trained IBCLC. All the IBCLCs I know want infants to be fed. Feeding an infant is a minimum goal, not a thing that is “best.” IBCLCs do not encourage parents to risk their infants’ health in pursuit of exclusive breastfeeding. They have the expertise to help parents determine if their infants are receiving enough nutrition through breastfeeding and how to appropriately supplement if needed. They help parents meet their own goals whether it be to exclusively breastfeed, bottle-feed expressed breastmilk, inclusively breastfeed, combination feed, or wean.

In order to fully support breastfeeding, we need to support families. We do not need to tell parents that they should breastfeed; we need to remove obstacles so they can breastfeed. This is the work of the IBCLC. We can be their soft place to land.

#happyIBCLCday #fedisnormal #paidparentalleave #medicaidforall

Expressing Milk in an Emergency

Many people who pump breastmilk do not own a hand pump and rely on electricity for milk expression. If you are an exclusive pumper or just pump when you are separated from your baby, you know how important your breast pump is for your well-being and that of your baby. If your pump has ever malfunctioned, you have forgotten important parts, or if you have lost power, you may have experienced the inability to express milk when you needed to. There are alternatives to using an electric pump that may be helpful in these circumstances.

Hand Expression:

Learning to hand express is a valuable skill. Your hands are always available, so you can express milk even if you have no other equipment. The following video is one of my favorites for demonstrating hand expression. https://vimeo.com/65196007

Warm Jar Method:

Have you heard of the new silicon manual hand pumps? These use consistent rather than intermittent vacuum to remove milk from the breast. They work well for many who are lactating but if you do not own one, the warm jar method can also work. This method has been used for generations to express milk. First pour very warm water to fill a wide mouth canning jar. Pour slowly to avoid cracking the jar. Pour out the water and cool the rim so that the breast will not be burned. Center the jar over the nipple and hold it there. As the jar cools, a vacuum will form and milk will be drawn from the breast. Once the milk is flowing, you may try combining this method with hand expression.

Using Pump Supplies to Make a Hand Pump:

If you gave birth in the hospital, you may have been sent home with various pumping supplies that you didn’t use. Some of these supplies are used for hospital rental pumps and are not needed for personal use pumps. These supplies can also be used to make a hand pump! The following video shows how.


New Latching Video from Breastfeeding Medicine of Northeast Ohio

I am a big fan of therapeutic breast massage as taught by Maya Bolman, and shared on the website for Breastfeeding Medicine of Northeast Ohio, so I was very excited to discover that the website has a new video on latching. It shows how important it is to help your baby achieve chin contact before latching in order to stimulate a wide deep latch.

Video from Breastfeeding Medicine of Northeast Ohio


Positioning: It’s All About the (Baby’s) Chin.

Babies and breasts come in different shapes and sizes. This may be a very obvious statement but it bears consideration when we bring babies and breasts together. Suzanne Colson, Nancy Mohrbacher, and Christina Smillie teach us to lie back to achieve good positioning. This often works very well but not for everyone. If a parent lies back and the nipple points downward, the baby cannot get in a position where the chin contacts the breast under the nipple.

In the past, breastfeeding helpers taught the tickle (the lips with the nipple) wait for a wide open mouth, and RAM (rapid arm movement) method. Some providers suggest aiming the nipple toward the palate or brushing the upper lip with the breast and waiting for a wide open mouth. But what comes next? Often the baby’s head is pushed onto the breast and the baby can’t breathe and becomes frustrated. Or the baby is brought to the breast but closes their mouth on the way causing a shallow latch. Why is it so hard?

Again, breasts and babies come in different shapes. Some babies have very receding chins. Some breasts are very round and some are flatter or softer or smaller or larger or…

The best positioning for a particular parent and baby is to be sure that the baby’s chin contacts the breast before latching. Chin contact below the nipple allows a baby to achieve a deeper latch. There are many techniques that can help achieve this positioning (try Googling “laid-back breastfeeding” or “flipple” or “deep latch technique”) but the technique needs to match the shape of the baby and the breast so they come together in harmony.

I absolutely love the following photo for showing how to position your baby.

http://www.cwgenna.com/quickhelp.html (click on “Latching Your Baby 101”)

Whatever your shape or your baby’s shape, if you can achieve chin contact before latching, you may have a more comfortable latch. If not, you might just need more help from an International Board Certified Lactation Consultant.

Choosing a Breastfeeding Helper

Parents who are struggling with breastfeeding need high-quality, timely support in order to ensure they meet their breastfeeding goals. Because optimal breastfeeding is critical for the health of Baby and Parent, it is important that they receive the best help available.

There are many knowledgeable volunteer breastfeeding supporters that can help parents to breastfeed. Often this peer-to-peer help is all that is needed to resolve a breastfeeding difficulty. For more complicated problems such as low milk-supply, painful breastfeeding, babies who have difficulty latching, and slow weight-gain, it is important to get timely professional help in order to get back on track quickly.

I frequently see parents who have tried many other professional breastfeeding helpers and did not receive the help they needed. Time, energy, and resources may have been wasted. Delays in following the best interventions often result in parents not meeting their breastfeeding goals and babies missing out on optimal breastfeeding. High quality professional breastfeeding support may seem expensive but it saves time, effort, and financial resources in the the long run. Additionally, lactation help from an IBCLC is usually reimbursable by insurance.

Parents are often confused about the many different kinds of professional breastfeeding support providers available in the community. It is critical that parents have access to information regarding these differences so that they can make informed decisions about whom to hire for help. The following links explain the different types of breastfeeding supporters and the training required for each. Be aware that the term “Lactation Consultant” can be used by anyone, no matter what training or experience they have with breastfeeding.



The following article explains why I chose to become an International Board Certified Lactation Consultant.


This site  is dedicated to helping parents find answers to their breastfeeding concerns and to provide a platform for posts regarding current breastfeeding topics. It has recently been optimized to be smartphone friendly. Breastfeeding information is easily accessible by clicking on the Menu link or Search box located at the top of the site.

None of the information on this site is intended to replace medical advice. Please consult your health care provider for medical advice. If you are not able to solve your breastfeeding difficulties, please contact a Board Certified Lactation Consultant (IBCLC) or breastfeeding peer helper for more assistance.

Find a Lactation Consultant

Find a La Leche League Leader

Other Breastfeeding Support

The contents of this site are the property of Laura Spitzfaden. Please do not reproduce anything without permission. You are welcome to link to my site if you wish to share any of the material you find here.

Contact me: laura@feedthebabyllc.com

USDA Child Nutrition Program, Breastfed Toddlers and Day-Care

Under the USDA Child Nutrition Program guidelines, infants and children 1 year of age and older, who are in licensed day-care programs, must be offered fluid cow’s milk (or approved alternative milk) in order for their day-care providers to be reimbursed for their meals. This is in conflict with what is best for employed moms of breastfed toddlers and their day-care providers, who have limited breastfeeding friendly options under these guidelines. Read more USDA Child Nutrition Program, Breastfed Toddlers and Day-Care

One Possible Reason for Low Milk-Supply

“Why Some Women Don’t Have Enough Breastmilk for Baby: Important Role of Insulin in Making Breast Milk Identified”


This is very exciting news and may be one of the reasons why some moms have milk-supply difficulties.  Moms with gestational diabetes and diabetic moms tend to have a slower increase of full milk-supply and now there is evidence that shows why this may be true.

For those who are interested in reading the original research:


These are early findings but if you have low milk-supply and insulin resistance, you might consider using dietary modifications to lower your blood sugar in order to increase your milk-supply.

One dietary modification that may be helpful in lowering blood sugar is magnesium supplementation. Low magnesium is associated with insulin resistance and sugar cravings.


Many breastfeeding moms notice a milk-supply drop coinciding with sugar cravings during certain times of their menstrual cycles and have found that magnesium (and calcium) supplementation can help them to avoid this supply drop.

Since many of us are low in magnesium, supplementation of this mineral may be one dietary intervention that could positively affect blood sugar and milk-supply.

Laura Spitzfaden, LLLL, IBCLC


Maintaining a Robust Milk Supply When Parent and Baby Are Separated

I was inspired to write this post due to some recent helping situations.  I decided to compile all this information in one place.  I may add to it later.

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.comcare-plan-for-milk-supply/)  When parent and baby are together, it is beneficial to keep baby skin-to-skin and allow free access to the breast.  A baby is usually better at maintaining a milk supply than a pump and the extra nursing stimulates breasts to make more milk.

When a breastfeeding parent 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%!

Read more Maintaining a Robust Milk Supply When Parent and Baby Are Separated

Why I Became an International Board Certified Lactation Consultant

In Honor of IBCLC day, March 6th 2013, I decided to explore the reasons why I chose to become an IBCLC, though there are easier and less costly pathways to providing professional breastfeeding support.

I had already been an active La Leche League volunteer leader for nearly 12 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 parents overcome breastfeeding difficulties and realize their breastfeeding goals.  I did not believe, however, that this was adequate training to provide professional breastfeeding services. Read more Why I Became an International Board Certified Lactation Consultant

How Tongue-Tie and Lip-Tie Affect Breastfeeding

Tongue and lip-tie are common causes of nipple pain, uneven breast drainage, slow weight gain and low milk supply. Many physicians do not properly assess for tongue or lip-tie or recognize their impact on the breastfeeding relationship, leaving babies vulnerable to early weaning.

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.  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 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 parent or baby may indicate that tongue-tie is affecting breastfeeding.

Signs in parent:
•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
•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.


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.



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 the parent 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.

For more information, visit the following links:






American Academy of Pediatrics–Tongue-Tie








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

Milk Sharing

I was inspired to write about milk-sharing when I read this article by Amber McCann, IBCLC.


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.  [Update] La Leche League International offers guidelines on human milk sharing. 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. Read more Milk Sharing

First Days of Breastfeeding

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. Parents with gestational diabetes may even consider expressing and freezing some colostrum while pregnant, in case supplementation is indicated after birth.  This article written by By Deanna M. Soper, PhD and posted at the Breastfeeding USA website outlines the benefits and concerns regarding milk expression before birth.

***Edited 2017*** A new study in the Lancet suggests that prenatal colostrum expression in low risk pregnancy is safe.

Advising women with diabetes in pregnancy to express breastmilk in late pregnancy (Diabetes and Antenatal Milk Expressing [DAME]): a multicentre, unblinded, randomised controlled trial Forster, Della A et al. The Lancet , Volume 389 , Issue 10085 , 2204 – 2213 June 2017

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://www.bfmedneo.com/BreastMassageVideo.aspx (From Breastfeeding Medicine of Northeast Ohio)

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



Immediate skin-to-skin contact is best for parent 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 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 parent’s bacteria.  Babies become colonized with the bacteria they contact in the birth canal and on the parent’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 parent’s bacteria, may also help prevent a hospital acquired bacterial infection of the breast or nipple.

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 parent and baby for routine procedures.  Baby’s temperature stabilizes best on parent’s chest and breastfeeding is facilitated by protecting this critical first hour.  Even after cesarean birth, baby can be immediately placed on parent’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 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 if baby is not latching or not transferring milk within the first 1-3 hours.  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-tieThis 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 parents notice this increase around the third or fourth day.  Parents 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

You 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