“Breastfeeding is an instinctual and natural act, but it is also an art that is learned day by day.”
~La Leche League
Breastfeeding can seem confusing, mysterious, overwhelming, and hard. But the truth is that breastfeeding is just as natural for your body and baby as labor and birth. In general, just as you can trust your body to grow a baby within yourself and then bring it forth into the world, you can also trust your body to continue to nourish your baby through your breast milk, and you can trust your baby to know how to nurse. That being said, there are some things that are helpful to know ahead of time to help ensure a positive, fulfilling, breastfeeding relationship with your baby.
How Breastfeeding Works
Your ability to nourish your baby begins with puberty and the growth of your breasts. That ability continues as soon as you become pregnant as your body immediately works to grow more ducts and support structures within your breasts so they will be capable of making plenty of milk. In fact, by 16 weeks in pregnancy, your body is capable of making milk for your baby.
Women don’t typically begin lactating until the end of pregnancy, due to hormones that the placenta secretes, which suppress lactation. Once you have delivered the placenta, the source of all those lactation suppressing hormones is now gone. At the same time, your body has also been working to increase your prolactin (the hormone responsible for making milk) up to 10 – 20 times the level you had before you got pregnant. Most women will begin leaking colostrum sometime in the last couple of months of pregnancy, and it will be ready to go when you latch your baby for the first time. Milk production in the first 2 – 4 days after birth has nothing to do with how much baby nurses. In the first few days after birth, your body will have an endocrine response (based on hormone balance) which triggers your body to start up your milk supply quickly. Once your milk supply is established–this is typically referred to as your milk coming in–then the endocrine response gives way to an autocrine, or a supply-and-demand response. Simply put, the more you nurse, the more milk your body will make.
You may worry about how long it will take for your milk to “come in.” This phrase is misleading, because it implies that you don’t have any milk in the first few days. It’s good to remember that your baby isn’t actually born hungry, and colostrum is really your baby’s first milk! Your baby will spend the final weeks in your womb storing up a special layer of fat. They burn this fat in the first few days for energy (and thus lose a little weight) while they are waiting for the transition to mature milk sometime between days 3 and 5. In the meantime, colostrum serves its own purpose by balancing your baby’s blood sugar, helping line and colonize their gut, and protect them with its high concentration of antibodies.
In addition, babies are born with tiny stomachs: they need only a teaspoon of colostrum per feeding at the beginning, and that is precisely what they get while they are nursing in the first couple of days. Once your milk transitions, your baby will definitely get hungry, their stomach will start stretching to accommodate the larger volume, and they will regain the weight they initially lost. Newborns are born with a strong instinct to nurse, and it is imperative that a newborn nurse as much as they want to in the first days of life.
Breastmilk Composition
Breastmilk is amazing, and it provides much more for your baby than just food. Breastmilk contains 3-5% fat, about 1% protein, and about 7% sugar. In addition, breastmilk contains hundreds of proteins, enzymes, and antibodies that help develop your baby’s immune system and provide protection from disease, harmful bacteria, and autoimmune disorders. The thymus is the primary immune-system organ in children through puberty, and breastfed babies have thymuses twice as large as formula fed babies.
Special sugars in colostrum called oligosaccharides not only feed the good bacteria which your baby needs to establish a healthy digestive tract, but also block any pathological bacteria from infecting the baby. Breastmilk has high levels of a substance called secretory immunoglobulin A (SIgA), a type of antibody that migrates from the bloodstream to the surface of mucous membranes and kill invaders before they enter the body. This eliminates the need for the inflammation (fever) immune response to begin in a baby who needs all their energy to eat and grow. Other benefits of breastmilk include significant reductions in the risk of leukemia, obesity, eczema, ear infections, RSV, rotavirus, and meningitis. And this is just the tip of the iceberg!
How to Breastfeed Your Baby
Babies are born knowing how to nurse. Just like all mammals, a human baby, if left to their own devices, will crawl up their mother’s stomach and latch on to the breast with no assistance. Google “breast crawl” and you’ll find videos. Granted, it’s hard to allow a baby to do this unassisted. They are awkward, stop to rest, take a long time, and in general aren’t very efficient. But they can do it, and what’s more, if they are left to their own devices, the baby will latch perfectly. In general though, we don’t want our babies to have to work for an hour every time they want to nurse. So here are the things to remember while assisting your baby to latch.
Position
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There are many positions, but the most common are pictured here. The most important thing to remember, no matter your position, is that you want your baby to have a neutral spine and neck – their ear, shoulder, and hip should be in a straight line, tummy-to-tummy with you. If possible, the baby’s mouth should be positioned slightly lower than your nipple so that the baby has to lift their chin to reach the breast.
Latch
A common misconception surrounding breastfeeding is that the baby sucks on your nipple, like we suck on a straw, to get milk. In fact, the baby draws your nipple far back in their mouth to their soft palate (see image above, left), creating a vacuum while massaging your areola with their tongue and jaw to stimulate your breast to squirt milk down their throat. Ways to tell your baby has a good latch include watching for a wide open mouth with lips flanged out around the areola, seeing their whole jaw move while sucking, and not experiencing pain past the initial latch. After the nursing session is over, your nipples should look symmetrical, with no creases, dents, or damage. Latching on is often uncomfortable in the first days of nursing, but sharp pain during the whole nursing session is not normal.
Frequency & Duration
Though how often and how long a baby desires to nurse varies greatly, in general, a baby older than 1 day old should nurse 8 to 12 times in a 24 hour period. They should have an active period of sucking and swallowing of 5 to 10 minutes on each breast for each feeding. The younger the baby, the more likely this active nursing will be spread out in small increments over the course of the whole feeding. The actual amount of time nursing varies greatly with the baby and the circumstances: it could range from 10 minutes to an hour in the first days. With such a broad range of normal, you can tell that your baby is nursing enough by keeping track of his diapers. Your baby should have about the same number of wet and soiled diapers as he is days old. This rule holds for the first 5 days, and then the numbers level out and become more individualized. A satisfied baby who is a week or more old will have 4-10 wet and 1-6 soiled diapers a day.
Potential Problems
If all goes well, you and your baby will be enjoying all the benefits of breastfeeding without having to worry about anything. But what if you’re running into issues? The first thing to do is to get help right away! Don’t wait! The rules for solving breastfeeding problems are simple: Feed your baby, protect your milk supply, and get help to find a workable solution unique to you and your baby. The second thing to remember is that if there is an insurmountable obstacle to your breastfeeding journey, that is not your fault. Sometimes we need donor milk or formula. This is not a failure. Don’t quit on a bad day – get help from someone supportive of your desires. If you recognize any of the following issues, or are having any other problems not listed here, call your midwife or a lactation consultant right away!
Painful Nipples
Though there is usually some discomfort during the first week or two of your breastfeeding relationship, truly painful, damaged nipples can completely derail your desire to breastfeed. The most important thing to avoid this is to be sure your baby has a good latch each time. A nipple that is properly pulled deeply back to the soft palate of the baby’s mouth will not get damaged, and any discomfort usually confines itself to the initial latch-on, which shouldn’t last longer than 2-4 weeks or so. If you experience pain past the initial latch while nursing, gently break the seal with your finger and re-latch the baby. Use coconut oil or lanolin on your nipples after each feeding to soothe and prevent chapped or cracked nipples. Cool compresses are also helpful.
Tongue and/or Lip Tie
Sometimes the bands of tissue that hold your baby’s tongue or lips, called the frenulum, are so tight that the baby cannot latch properly or cannot properly transfer milk. Symptoms include: 1) Experiencing nipple pain beyond the initial latch or any pain at all past 3-4 weeks old, 2) Baby isn’t gaining weight or producing enough wet/poopy diapers, is fussy all the time, or won’t sleep for any long stretches, 3) Baby is taking consistently longer than 40 minutes to finish a meal even with breast compressions, 4) Clicking sounds when nursing.
Your midwife will do a basic assessment for oral tethers during your baby’s first exam at birth. Further assessment may be necessary either by a Lactation Consultant or a Pediatric Dentist especially if either baby or mom is experiencing the above symptoms.
Jaundice
Jaundice (yellow skin) is rarely an issue in a full-term baby. Most babies have a small to moderate amount of jaundice in the first days to weeks after they are born. Jaundice is only a problem in a full term baby if the baby is less than 24 hours old, or the baby is not nursing or eliminating. For a more thorough discussion of Jaundice, please see our resource specifically on this topic.
Low Milk Supply
One thing to keep in mind when trying to determine if there is a supply issue is that in the first few days, you are making a few teaspoons of colostrum at a time, while your body kicks milk production into high gear. This is not a low supply. This is normal. It is also normal to see what looks like a drop in milk supply after the first few weeks. This is simply your body matching your supply to meet your unique baby’s needs instead of making as much milk as possible due to the initial endocrine response. If your baby is satisfied and growing, you can rest assured that you are making enough milk.
That said, some mothers do struggle with their milk supply. While there are some women who have structural, hormonal, and/or metabolic issues that keep their milk supply low, this is rare and milk supply issues often stem from other causes. These biological hurdles are not a failure, and these women will need to supplement their babies with donor milk or formula. This is normal in such circumstances!
Most often, however, supply issues stem from other causes such as tongue tie or poor latch. A baby with a poor latch (whether from positioning or tongue tie) cannot transfer milk effectively, and your body will slow down production since the demand is lower. The symptoms of low supply mimic those of tongue or lip tie. If you’re not sure, please check with your midwife and/or a lactation consultant as soon as possible to troubleshoot this problem and help you find a good solution.
Another common cause of low supply is scheduling your baby’s feedings. While babies thrive on routine, breastfeeding is a strict supply and demand system, and your baby needs to nurse completely on demand, especially in the early weeks. There will be room for scheduling later, but usually not before 6 months old when solids can be introduced. Scheduling like this can and does lead to low milk supply and failure to thrive (baby doesn’t gain weight or grow appropriately), resulting in weaning earlier than you wanted to. When books or advice conflicts with your baby’s behavior/needs or your instincts, drop the advice, and listen to yourself and your baby!
Some women try to correct low milk supply by using lactation supplements of all kinds. In general, though, the single most important factor in boosting supply is to stimulate the breasts with effective nursing and/or pumping. No supplement, cookie, or recipe can make up for a poor latch, a tongue tie, or strict feeding schedules, though they can sometimes help. Your midwife and/or a lactation consultant can make recommendations based on you and your baby’s circumstances.
Overactive Let-Down and Oversupply
Some women make so much milk that they never feel empty, no matter how much the baby nurses. This is often accompanied by a very forceful let-down reflex, and the baby feels like there’s a fire-hose aimed at the back of their throat. Symptoms for the mom can include sore breasts, clogged ducts, and a tendency towards mastitis (breast infection). For the baby, they may be fussy, spit-up a lot, choke, sputter and pull off the breast often while feeding. In addition, they are often gassy, and have explosive watery, green colored bowel movements which contributes to being irritable. These babies often gain weight really well, but are a bit unhappy overall. They are often diagnosed with colic, reflux, or the mother is told that she must eliminate foods from her diet that the baby may be sensitive to. There are two main things to help this issue. First, nurse semi-reclining or lying down with the baby on top of the breast so that the forceful let-down has to work against gravity. Second, nurse your baby on one side for several (3 to 5) feedings before switching to the other side. If the other side gets very uncomfortable, pump off just enough milk to ease the discomfort. This will encourage your milk supply to lower a bit, and it will give the baby more fat in his milk which will slow down his digestion, easing the reflux/colic/sensitivity symptoms.
Dysphoric Milk Ejection Reflex (D-MER)
This is a very rare physiologic condition in which the normal drop in the hormone dopamine that usually takes place right before and during breastfeeding becomes extreme. This results in mothers feeling a range of negative emotions from depression to anxiety to anger while breastfeeding. The period of time that she experiences these emotions is short and only occurs during let-down. This is a different condition entirely from postpartum depression and rarely requires treatment, but it is important for those affected to be able to identify what is going on.