Before Birth
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.
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)
http://newborns.stanford.edu/Breastfeeding/HandExpression.html
Birth
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-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 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 www.feedthebabyllc.com
