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Establishing Your Milk Supply: Starting Out Right
by Anne Smith, IBCLC
While breastfeeding is the most natural thing in the world, babies are not born knowing how to nurse (although some do get the hang of it sooner than others). The art of breastfeeding in something that you learn by doing, and it gets easier with practice. In the old days, young women grew up seeing their family members and friends nurse. In today's society, many women have never seen anyone nurse a baby. The idea of taking classes or reading books to learn about breastfeeding would have made our great-grandmothers laugh, but in today's world, it makes sense to learn as much as you can about breastfeeding before your baby is born. If possible, attend a prenatal breastfeeding class. Many hospitals, doctor's offices, and health departments offer them at no charge, or for a small fee. Attend La Leche League meetings during your pregnancy. They provide a wide range of information about not only about nursing, but also about parenting, nutrition, childbirth options, and more. A lending library is available, and often has books that may not be found in your local library. You will also get a chance to meet other mothers who can quickly become new friends, and provide a built in support system to help you get through the challenging early weeks of nursing. Just seeing other mothers happily nursing their babies in a relaxed environment can help boost your confidence level. To find out about groups in your area, ask your doctor or childbirth educator, or call 1-800-LALECHE.
There are many books about breastfeeding on the market, and some are better than others. The Complete Book of Breastfeeding, Nursing Your Baby, The Nursing Mother's Companion, and Nursing Mother, Working Mother are good basic reference books. If you only buy one resource book, The Womanly Art of Breastfeeding is by far the best. It not only contains detailed information about all aspects of nursing, but also goes into detail about nutrition, starting solids, attachment parenting, and weaning. This is a book that you will refer to over and over again, not just during the early days of nursing. It is available from your local La Leche League group, or the library or bookstore.
One thing is for sure: childbirth and breastfeeding are two experiences that no amount of reading, attending classes, or watching videos can really prepare you for. What they mostly do is tell you about what the "average" birth experience or the "average" breastfeeding experience will be like. You need to remember that your baby hasn't read those books or taken those classed," and he doesn't have a clue that he is supposed to behave like the "average" baby. In fact, there is no such thing as an "average" baby. Each baby is unique, and so each nursing experience will be different. Often the mothers who have done the most intensive prenatal preparation are the ones who have problems adapting when things don't go 'right by the book'.
In addition to reading books or taking classes, it is important to have a support system in place in case you have questions (and you probably will) or if problems do develop. Find out about resources in your community. Often a La Leche Leader or a friend who has nursed can provide the information and support you need. If medical problems develop, find out how to contact a Lactation Consultant in your area. Your doctor, childbirth educator, or La Leche Leader should be able to put you in touch with a Lactation Consultant. Often your doctor doesn't have the specialized training in lactation to provide the intensive help that an IBCLC (International Board Certified Lactation Consultant) or La Leche Leader can.
There are some basic things you can do from the beginning to help get breastfeeding off to a good start.
- Breastfeed early. Put your baby to the breast as soon as possible after birth, while his sucking instincts are strongest. Babies are most alert during the first hour after birth, and soon settle into a sleepy stage than can last for hours or even days. Try to take advantage of this early alert period. Early nursings, before your milk comes in, let him practice while your nipple is soft and easy to grasp. His sucking helps contract your uterus, reduces bleeding, and helps speed up delivery of the placenta.
- Nurse often. Room in with your baby, and learn to recognize his feeding cues (such as wriggling around, rapid eye movements, putting his hands in his mouth). Try not to wait until he is crying before you offer the breast. When he is crying and upset, he is less likely to be willing to settle down and nurse, and may respond by shutting down and falling asleep. Crying is a late feeding cue -- learn to recognize the early ones. Newborns usually need to nurse 10-12 times or more in 24 hours. The more he nurses, the sooner your milk will come in, and the more milk your body will produce. Make sure that you offer the breast at least every 2-3 hours during the day, with no more than one 4 hour stretch during the night. Since newborns tend to be sleepy, you may have to wake him up for feedings (see article on Waking the Sleepy Baby). If you are separated from your baby after birth, or if he doesn't nurse well, use a hospital or professional grade pump (015 Classic, 016 Lactina Select, or Pump In Style) to stimulate and maintain your milk supply.
- Nurse for comfort as well as nourishment. Plan to spend most of your time nursing in the early weeks. Babies nurse for lots of reasons, and they are all valid. You really can't overfeed him, so put him on the breast whenever he fusses. One of the greatest things about nursing is that you always have a built in pacifier -- it works if he's hungry, tired, lonely, sick, or scared. Don't be afraid to use the breast as a pacifier -- it works, makes your baby happier, builds your milk supply, and forces you to stop and rest. If friends and family members want to help, let them take care of you while you take care of the baby. While everyone wants to hold the baby and give you a break, the most helpful thing they can do at this stage while you're are resting and building your milk supply is to cook, clean, run errands, entertain older children, etc. There will be plenty of opportunities later on for them to play with the baby.
- Set up a 'nursing station' in the living room and the bedroom. Get all the supplies you will need together so you don't have to move once you get settled: pillows, diapers, change of clothes, towel or cloth diaper for leaks or spit up, nursing pads, wipes, change of crib linens, bottle of water, remote control, book to read, etc.
- Don't limit the time he spends at the breast. Let him nurse as long as he seems interested. He needs to nurse long enough to get the high calorie hindmilk that comes later in the feeding, after the milk lets down. Especially in the early days of nursing, it may take several minutes for the let down reflex to 'kick in'.
- Offer both breasts at a feeding. Nurse him at least 10-15 minutes on the first side, then burp and change him and offer the other breast. Next feeding, begin with the breast he nursed on last. Many babies will only take one breast at a feeding once your supply is well established, especially if you have a plentiful supply, but in the beginning, you need to stimulate both breasts.
- Don't be surprised if your baby 'cluster feeds'. This means that he may nurse constantly for several hours, then conks out and sleep so soundly you can't wake him up for four or five hours. It really doesn't matter, as long as he is getting enough to eat. For most babies, this means nursing at least 8 times in 24 hours. However, if your baby has regained his birth weight by day 3, there is no reason to set your alarm and wake him up every 2 hours to nurse. As long as you keep track of his urine and stool output and his weight gain, it really doesn't matter whether he nurses every one and a half hours or every four hours, whether he took both breasts or one, or whether he nursed for five minutes or thirty. Remember that the mythical "average" baby doesn't really exist.
- Avoid artificial nipples and supplemental feeding during the early weeks of nursing. (See article on Introducing Bottles and Pacifiers to the Breastfed Baby for more details). While some babies switch back and forth from breast to bottle easily from the first day, many babies will become nipple confused if you introduce artificial nipples before they have mastered the art of breastfeeding.
Colostrum, the yellow fluid that your breasts start producing during pregnancy, is the perfect first food for your baby and will meet all his nutritional needs for the first couple of days until your milk comes in. (Interesting piece of trivia: in lower mammals, newborns die if they don't receive the immunities from their mother's colostrum. Ask someone who raises horses or puppies. The mother horse who refuses or is unable to nurse her newborn is dooming him, unless another newly lactating horse can be found ASAP. Thank goodness this isn't true for humans!) While colostrum isn't quite as important to human babies, it does provide immune factors that newborn infants can't receive anywhere else. It is easy to digest, and is full of antibodies and immune factors. Colostrum is often called "baby's first vaccine".
During the first couple of days after your baby is born, he will take in only teaspoons (not ounces) of this precious fluid. His immature kidneys are not meant to handle large volumes of fluid at this time, and the colostrum has a laxative effect that clears the meconium (the black tarry first stool) out of his system. Excreting the meconium will help him avoid becoming jaundiced (see article on Jaundice). Your baby is born with extra fluid in his tissues, and will excrete it during the early days. Most babies will lose some weight in the first couple of days after birth; the average seven and a half pound baby will lose about 7% of his birth weight, or around 8 ounces. This is normal, and he will quickly regain his weight in a few days once your milk comes in. Babies don't need water, even when it is hot outside. Human milk contains plenty of water.
Giving formula supplements at this early stage can cause all kinds of problems, including a decrease in your milk supply. Formula takes longer to digest than breastmilk, so your baby stays full longer and is less likely to nurse as often as he needs to stimulate your supply. While many babies tolerate formula well, the younger your infant is when he is exposed to artificial milk, the greater the chance of allergies or digestive problems. The longer you wait to introduce formula (if you introduce it at all) the better.
If supplements are medically indicated, it is best to use alternate feeding methods rather than bottles. See the article on Introducing Bottles and Pacifiers to the Breastfed Baby for detailed information on alternate feeding methods such as cup, syringe, tube, or finger feeding.
Make sure that your baby is latched on correctly and is nursing effectively. The article on Sore Nipples contains detailed information on how to make sure your baby is positioned and latched on correctly. His mouth should be open wide, his lips flanged out, his tongue extended over his gum and under your nipple, and he should have not just the nipple but some or all of the areola (the dark area around the nipple) in his mouth as well. He should be pulled in close with his chin and nose touching the breast. His whole body should be facing yours, tummy to tummy, so that he doesn't have to turn his head to nurse.
Learn signs of effective, nutritive nursing. Look for a long, drawing, rhythmic motion along his jaw-line, and a wiggling at his temple. You should be able to hear him swallowing after your milk comes in. Some babies will stay on the breast for long periods of time, but will 'flutter suck' ineffectively in their sleep, and won't get the milk they need or supply you with the stimulation to produce more.
Learn how to tell if your baby is getting enough milk. This is very important, since you can't measure breastmilk like you can formula. Keep track of urine and stool output, and check his weight early and often. (see article on How to Tell if Your Baby is Getting Enough Milk) for more details on this important topic.
Your milk will 'come in' 2-5 days after birth, usually on the third day. For information on how to prevent and treat engorgement, see article on Engorgement.
For the first couple of days, your breasts will produce sticky yellow or gold colostrum. Once your milk comes in, you will produce transitional milk -- a mixture of colostrum and mature milk, which may be yellowish and creamy looking. During the next week or so, less and less colostrum is produced, and by the time your baby is two weeks old, mature milk has replaced the transitional milk and no more colostrum is produced. Even if you only nurse your baby for a few days or a couple of weeks, you are still providing him with important immune factors. (See Article on Breastfeeding Benefits: How they Add Up). Of course, very few mothers who make it through the first two weeks of nursing will give up at that point. That's just when you are over the hump and things are starting to get easier. Most breastfeeding problems (sore nipples, engorgement, latch on problems, etc.) will be resolved after the first two weeks.
I always think of the first two weeks after birth like this: you are in the "survival mode". You do whatever it takes to help you make it through the early weeks of parenting/breastfeeding.
Days three and four are usually the roughest, and the time when most mothers are likely to give up and switch to formula. There are many reasons for this: the physical stress your body has been through (you often just don't feed good -- even with a natural childbirth with no complications, you are still physically drained, and you may be dealing with additional stresses like constipation, hemorrhoids, episiotomy stitches, or recovering from a c-section), the hormonal upheavals, sleep deprivation, and the overwhelming pressure of being the one person totally responsible for the nourishment of this new little person in your life. While I understand the reasons for mothers being released from the hospital after 48 hours, I don't think that many of the health professionals who decided to send you home so soon have done a good job of providing postpartum support, especially for breastfeeding. In most cases, you are home before your milk even comes in, and that's why the support you have once you leave the hospital is crucial.
During the first 48 hours after birth, both you and your baby are recovering from the stress of giving birth and being born. Babies tend to be sleepy during this time, and while you will be sleepy as well, it is often difficult to get much rest in the hospital. There is so much going on -- blood pressure checks, temperature checks, visitors in and out, dealing with paperwork, getting the baby's picture taken, having him circumcised, etc.
During your 48-hour hospital stay, your baby will alternate between sleeping and nursing. Because he is born with extra fluid in his tissues, he really isn't hungry during that time, but nurses for comfort and because he loves to suck. Babies even suck their fingers in utero. Many mothers tearfully call me on day three or four and say "But we did so well in the hospital! He nursed and slept, and everything was fine. Now he's fussy, my nipples are sore, my breasts are hard, and I don't know what to do!"
It's normal for babies to become agitated and fussy on the third or fourth day, because they are feeling hunger pangs for the first time. Their little tummies rumble and growl, and they don't like this new feeling one bit. They have no way of knowing that if they go on the breast, they will get milk and feel good again. They will soon figure it out, but it is a learning process. Be patient and hang in there.
Do whatever you have to do to survive the first two weeks. If you have to use slings, swings, bottles, pacifiers, formula, or pain medicine, use them and don't feel guilty about it. The most important thing is that you make sure your baby gets enough to eat while lowering your stress level, enjoying your baby, getting your strength back, and continuing nursing. It really won't matter down the road, and sometimes using these things can make the difference between continuing to nurse or giving up in the early days.
Be prepared for growth spurts. These are periods of time when your baby wants to nurse constantly and never seems satisfied, and usually occur around 7-10 days, 3 weeks, 6 weeks, 3 months, and 6 months. Remember that they rarely last longer than a few days to a week. If you have been feeding every 1-2 hours around the clock, and your baby doesn't go any longer stretches than that in 24 hours, consult a Lactation Consultant if this pattern continues longer than a few days. The baby who nurses 'constantly' for several hours, then sleeps for a 4 or 5 hour stretch, is probably still getting in his minimum of 8 feedings in 24 hours, and is likely to be getting enough to eat. However, if he nurses 'constantly' around the clock with no long stretches between feedings and never seems satisfied, he may not be getting enough milk for a variety of reasons, and a consultation to discover the cause is indicated.
Know When to Ask for Help
- Your baby is not latching on well, or nursing just doesn't "feel right".
- Your breasts are engorged, or you are having breast or nipple pain, especially after the first couple of weeks. Breastfeeding is not supposed to hurt!
- Your baby is several days old and is not having 6-8 wet diapers and several bowel movements in each 24 hour period.
- Your baby is sleepy and hard to wake up for feedings. He is nursing less than 8 times in 24 hours.
- There are special circumstances such as jaundice, prematurity, low weight gain, cleft lip/palate, or neurological problems.
- You develop a breast infection (mastitis) or plugged ducts.
- You intend to return to work or school, or to be separated from your baby due to travel or hospitalization.
- You have any questions or problems related to breastfeeding.
Remember that nearly all breastfeeding problems can be solved if you are strongly committed to nursing your baby, and you receive advice and encourage from a knowledgeable breastfeeding professional. Don't ever be afraid to ask for help.
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