Breastfeeding

Breastfeeding or bottle feeding your newborn baby is a personal decision. If you choose to breastfeed, it will be helpful if you are in a supportive environment and have resources to assist you with questions you may have or problems that may develop.  

• Consider attending a series of La Leche League meetings or reading La Leche League's book on breastfeeding (The Womanly Art of Breastfeeding) before the birth of your baby.
  
  
• Ask other breastfeeding mothers for advice.
  
  
• A supportive network including other like-minded mothers helps with the commitments of this style of feeding.
  
  
• If you are undecided at birth time, consider a 1-month trial. It is easy to go from breastfeeding to bottle-feeding.
  
  
• The first month of breastfeeding is the most difficult, so if you get through that period, the rest will be easier.

• The ideal food for human infants is human milk. Human milk contains all the right ingredients—protein, carbohydrates, fats, vitamins, minerals, and water—in just the right balance. No formula can make that claim. Infant formula manufacturers attempt to artificially duplicate human milk. Formula feeding is a practice that is relatively recent—about 60 years—compared to the beginning of humankind (not to mention all other mammals) relying on breast milk.
  
  
• Formula does not contain the disease-fighting factors or the digestive enzymes that breast milk has. The nutrients in formula are more difficult for a baby to digest and absorb than the nutrients in human milk, requiring the baby to handle excess waste. Some formulas may have a less than optimal composition by containing too much salt and/or not enough cholesterol, fats, lactose, zinc, and iron, among other nutrients.
  
  
• Some infants fed a cow's milk–based formula may develop allergies to the proteins in the cow's milk. Infants who are allergic to cow's milk often are also allergic to "hypoallergenic" (non–allergy-causing) soy formulas.
  
  
• During the early months, a formula-fed baby may develop signs of allergy to or intolerance of a particular formula. These signs may include the following:
  
  
  • Bouts of crying after feeding
    
    
  • Vomiting after most feedings
    
    
  • Persistent diarrhea or constipation
    
    
  • Colic with a distended tense painful abdomen after feeding
    
    
  • Generally irritable behavior
    
    
  • A red, rough sandpaperlike rash especially around the face or anus or in both places
    
    
  • Frequent colds and ear infections
    
    
  • Red itchy rash especially in the folds of the elbow and knee joints
    
    
• These signs, or the baby's preference, may lead you through a series of different formulas, often each more expensive than the last.
  
  
• Formula-fed infants may be exposed to a variety of environmental substances used during the preparation of the formula or carried as a minor contaminate from which breastfed infants are protected.

With rare exceptions, breast milk is the preferred feeding for infants and confers unique benefits.

Breastfed babies (for at least 6 months) may be at reduced risk for many acute and chronic diseases, including gastrointestinal tract infection (like diarrhea), lower respiratory tract infections (like a cold), urinary tract infections, otitis media (ear infections), and allergic reactions (like atopic dermatitis and asthma).

The effect of breastfeeding in protecting against infection is well established. Infants who were fully breastfed for 6 months or more seem to have higher mental development when compared with infants who were never breastfed. Some studies show that the effects of breastfeeding may carry over and also protect young children and adolescents from becoming overweight.

• Milk has biologic specificity—meaning that every species of animal who breastfeeds their babies makes a milk that is unique for the young of that species.
   
• The amounts of nutrients change to match your baby's rapidly changing needs.
  
  
• The fat content increases during a feeding so that the baby gets the right amount of fat. Human milk contains the right kinds of fats along with an enzyme (lipase) that helps digest the fat.
  
  
• Cholesterol is high in human milk, lower in cow's milk, and very low in formulas. Cholesterol promotes brain growth and provides basic components of hormones, vitamin D, and intestinal bile.
  
  
• Milk (cow's, formula, and human) contains 2 main proteins: whey and casein. Whey is easier for humans to digest and is found in higher concentrations in human milk.
  
  
• Around 6 months of age, the baby's intestines mature and become less open to proteins that may harm the body as allergenic proteins (allergens). Giving only human milk until the intestines mature is the best way to keep potentially allergy-causing proteins out of baby's blood.
  
  
• Human milk includes helpful proteins not naturally found in milk made by cows or companies. 
  
  
• Human milk is fresh and contains more lactose (sugar) than cow's milk. Formulas add sucrose or glucose (other types of sugars).
  
  
• Vitamins and minerals have a higher bioavailability in human milk. In other words, the body uses most of what is in the milk. There is very little waste.
  
  
• The germs in the baby's environment, to which the mother has been exposed, cause the mother to produce antibodies to that germ, which are passed on to the breastfeeding infant.
  
  
• Breastfeeding relaxes mother and baby.
  
  
• Women who breastfeed have a lower incidence of breast cancer.
  
  
• Breastfed babies tend to be healthier.
  
  
• Breastfeeding is less expensive.

• Prepare your breasts by going without a bra for part of the day or wearing a nursing bra with the flaps down and exposing the nipples to air and the light rubbing of clothing. Avoid using soap on your nipples and areolas as soap dries the skin and encourages nipple cracking.
  
  
• Examine the nipples to determine if they are flat or inverted. Place your thumb and index finger on the opposing edges of your areola and press in firmly. If your nipple flattens or retracts (inverts) into your breast, it may be difficult for baby to grasp. If your nipples are flat or inverted, then wear a breast shield (breast shell or milk cup, not a nipple shield, which should be avoided) inside your bra throughout the last few months of pregnancy to gradually draw out the nipple.
  
  
• Take a breastfeeding class. Your hospital may offer breastfeeding classes as part of the childbirth class. These classes can put you in touch with a lactation specialist who may later be your personal breastfeeding consultant.
  
  
• Join your local La Leche League or other breastfeeding support group. Call (800) LA LECHE to find your local leader.
  
  
• Talk with supportive friends who encourage your feeding choices.
  
  
• Learn proper positioning and latch-on techniques.

• Within a few minutes after birth, most babies can be introduced to breastfeeding. Relax. Most babies take a few licks, sucks, and pause. Sucking in frequent bursts and pauses is the usual pattern for the first few hours and sometimes even the first few days. The first milk the mother produces, colostrum, is the best food.
  
  
• Breastfeeding also helps the uterus contract, which helps stop uterine bleeding.
  
  
• Try to room-in with your baby. When you see your baby begin to open its eyes, look around, and put his or her fist into his or her mouth, then it is time to offer your breast.
  
  
  • Try to make the nurses understand that you wish to breastfeed and that your baby should not be given sugar water or formula without you and your health care provider being aware and consenting.
    
    
  • You may need to have the nurses actually put a sign on your baby's bed restricting bottle-feeding.
  
  
• Try latching the baby on at the first signs of hunger. Do not wait until the baby cries, or you will teach the baby to cry to get your attention. The baby will get upset more quickly the longer you take to respond.

Many breastfeeding problems (sore nipples, insufficient milk, or mothers not enjoying breastfeeding) can be resolved with improving basic technique (see Multimedia File 1-5).

• Position yourself
  
  
  • Get comfortable sitting up in a bed, rocking chair, or armchair.
  
  
  
  • Place pillows behind your back, on your lap, and under the arm that will be supporting your baby as needed.
  
  
  
  • Use a footstool if you are sitting in a chair.
  
  
  
  • You can also lie on your side in bed facing your baby with pillows as needed to support your head, back, and upper leg (see Multimedia File 2).


• Position your baby
  
  
  • Start with baby only lightly dressed or even undressed to promote skin-to-skin contact.
  
  
  
  • Nestle your baby in your arm in a cradle hold (see Multimedia File 4). This involves cradling the baby with your arm on the same side as the breast being presented. The baby’s neck rests in the bend of your elbow, her back along your forearm, and her buttocks in your hand.
  
  
  
  • Turn your baby's entire body on its side so he is facing you, tummy to tummy.
  
  
  
  • The baby should be straight, not arched backward or turned sideways.
  
  
  
  • The baby should not have to turn his head or strain to reach your nipple.
  
  
  
  • Raise your baby to the level of your breast by putting a pillow on your lap or by using a footstool, otherwise you may strain your back and arm muscles or cause the baby to pull down on your breast.
  
  
  
  • Tuck your baby's lower arm into the pocket between her body and yours below your breast.
  
  
  
  • If her upper arm keeps interfering, you can hold it down with the thumb of your hand that is holding the baby.
  
  
  
  • If your baby is premature or has trouble latching on, try the clutch hold (see Multimedia File 5).
    
    
    • Sitting up in bed or in an armchair, set a pillow at your side, wedge it between you and the arm of the chair, and place your baby on the pillow.
    
    
    
    • Position your baby in close along the same side as the breast you are using and cup the back of the baby's neck in the same hand. Direct the baby's legs upward so that they are resting against the pillows supporting your back.
    
    
    
    • Be sure that baby is not pushing with its feet against the back of the chair or pillow, causing the baby to arch its back. If this happens, position baby bent at the hips with legs and buttocks against the back pillow.
    
    
    
    • Once baby is sucking well, wedge a pillow up against the baby's back to help hold the baby close.
    
    
    
• Present your breast
  
  
  • With your free hand, manually express a few drops to moisten your nipple.
  
  
  
  • Cup the breast, supporting the weight of your breast with palm and fingers underneath and thumb on top.
  
  
  
  • Keep your hand back toward your chest wall so your fingers stay clear of the areola, away from baby's latch-on site.
  
  
  
• Latch-on
  
  
  • Using your milk-moistened nipple as a tease, gently massage baby's lips, encouraging her to open her mouth wide.
  
  
  
  • The moment your baby opens her mouth wide, direct your nipple into the center of the baby's mouth and with a rapid movement pull the baby in very close to you with your arm.
  
  
  
  • Your baby's gums should bypass the base of the nipple and take in at least a 1-inch radius of the areola or the nipples will be sore after just 1 or 2 feedings. Babies should suck areolas, not nipples (see Multimedia File 1).
  
  
  
  • Many babies tighten or purse their lips, especially the lower one.
    
    
    • Help your baby open its mouth wider by using the index finger of the hand supporting your breast to press firmly down on your baby's chin as you pull the baby on.
    
    
    
    • You may be able to do this while the baby is latched on by using your index finger to evert (turn out) the baby's lips.


• Make adjustments for the baby's breathing: If your baby's nose seems to be blocked, pull baby's bottom closer to you, change the angle of baby's position slightly, or use your thumb to press gently on your breast to uncover the baby's nose.



• Support your breast
  
  
  • After you have baby correctly latched on, hold your breast throughout the feeding so the weight of your breast does not tire your newborn's mouth.
  
  
  
  • Supporting the breast will be less necessary as baby gets older and you will then have a free hand during most of the feeding.
  
  
  
• Breaking off: To avoid trauma to your nipples, do not pull your nipple from baby's mouth without first breaking the suction by inserting your finger into the corner of baby’s mouth, wedging it between the baby's gums.



• Positioning and latch-on skills for breastfeeding are all much easier than they sound once you get the hang of breastfeeding. Observing another mom breastfeeding first will help greatly if you have the opportunity.

• Breast enlargement during pregnancy occurs primarily from the growth of milk-producing glands. Differences in breast size prior to pregnancy are caused more by non–milk-producing fat tissue than by glands. Small-breasted mothers do not produce less milk than do large-breasted mothers.
  
  
• The more frequently your infant sucks (correctly), the more milk you produce, until you have both negotiated the proper balance.
  
  
  • It is unusual for a mother not to produce enough milk for her baby unless she is not breastfeeding correctly or frequently enough.
    
    
  • If your baby is gaining weight properly, then you are probably doing fine.
  
  
• Sucking on the breast in the same way as from an artificial nipple is likely to produce sore nipples and a reduced milk supply. This "nipple confusion" is why you should not give bottles to babies during the early weeks when they are still learning to suck properly. If a baby sucks incorrectly on a rubber nipple, the baby still gets rewarded with milk. The baby does not get milk when improperly sucking mother's breast.

Home care

For clogged milk ducts

• You may notice small, red, tender lumps within the breast caused by milk ducts (tubes) that have become clogged (blocked with dried milk or other material).
  
  
• The best treatment is to increase flow to open these blocked ducts.
  
  
• Increase breastfeeding frequency and offer the affected breast first.
  
  
• Pump the breast after breastfeeding if the baby is not emptying the breast.
  
  
• Keep pressure off the duct. Make sure your bra is not putting pressure on the duct.
  
  
• Do not wean baby at this time, or pain and complications may increase.
  
  
• Apply moist heat to the affected area to increase blood flow and healing. (When applying heat, be careful not to burn yourself or the baby. Try 10-20 minute sessions 2-4 times per day for 1-3 days. Applying a warm water bottle over a warm, wet washcloth is one method to apply heat.) A warm shower and massaging the area will allow resolution of this problem. 
  
  
• Sometimes the baby will refuse the affected breast because the milk develops a sour taste. Pump the breast and empty it as well as possible. Continue to offer that breast to the baby until baby breastfeeds again.

For sore nipples

• Expose sore or cracked nipples to the air as much as possible.
  
  
• Use a hair dryer on a low setting to dry nipples after breastfeeding.
  
  
• Wash only with water, never with soap, alcohol, benzoin, or premoistened towelettes.
  
  
• Unmedicated lanolin may help if nipple cracking is severe, but petroleum-based ointments and other cosmetic preparations should not be used.

Medical care

Breast inflammation (mastitis, possibly caused by infection)

• Seek medical care for symptoms or signs of breast infection.
  
  
• If you are breastfeeding and experience any of the following, call your health care provider:
  
  
  • Increasing pain in the breast
    
    
  • Chills
    
    
  • Sweats
    
    
  • Fever greater than 101°F
    
    
  • Increasing breast tenderness
    
    
  • Breast swelling and hardness
    
    
  • Redness
  
  
• Continue to breastfeed. Breastfeeding helps to empty the breast and prevent clogged milk ducts.
  
  
• Rest or get in bed at first sign of infection.
  
  
• Breastfeed and pump the affected breast as much as possible.
  
  
• Pump the breast to express milk on that side.
  
  
• Apply moist heat for 10-20 minutes at a time at least 4 times per day. Heat increases blood flow to the area, aiding in fighting infection. A warm shower with water on the affected breast may help facilitate healing. 
  
  
• Watch for additional signs of a localized infection called a breast abscess.
  
  
• The baby may not want to breastfeed on the affected side, so pump until the baby accepts the breast again.

• A delay in treating mastitis could lead to a more severe infection and possible breast abscess. If you are experiencing any of the following symptoms, go to a hospital’s emergency department.
  
  
  • A localized swelling that generally increases in size
    
    
  • Pain
    
    
  • Tenderness
    
    
  • Possibly warmth and redness if close enough to the skin surface
    
    
  • Fever greater than 101° F (May be associated with shaking chills alternating with sweating)
    
    
  • Breast abscess (pocket of infection)
  
  
• Surgical drainage may be indicated.
  
  
• Breastfeeding with the affected breast is generally stopped.
  
  
• A breast pump should be used regularly to empty the breast until breastfeeding can be restarted or symptoms could worsen.

|Web Links|

American Academy of Family Physicians, Breast Feeding: Hints to Help You Get Off to a Good Start 

American Academy of Pediatrics, A Woman's Guide to Breastfeeding

La Leche League

US Food and Drug Administration, Feeding Baby With Breast Milk or Formula

Media file 1: The complete suck cycle illustrates good feeding technique.

Media type:  Illustration

Media file 2: Reclined breastfeeding. Lie on your side in bed facing your baby. Use pillows as needed to support your head, back, and upper leg.

Media type:  Illustration

Media file 3: Crossover breastfeeding. Hold your baby across your body as you breastfeed.

Media type:  Illustration

Media file 4: Cradle breastfeeding. Nestle your baby in your arm in a cradle hold. This involves cradling the baby with your arm on the same side as the breast being presented.

Media type:  Illustration

Media file 5: Clutch breastfeeding. This position is good to try if your baby has trouble latching on to your breast.

Media type:  Illustration

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Author: Allahyar Jazayeri, MD, PhD, Professor of Obstetrics and Gynecology, Tehran University Medical School, Director of Maternal Fetal Medicine Fellowship Program, Medical Director of Perinatal Services, Bellin Health Hospital Center.

Coauthor(s): Frank Genco, MD, Consulting Staff, Department of Emergency Medicine, RHD Hospital.

Editors: Jerry Balentine, DO, Professor of Emergency Medicine, New York College of Osteopathic Medicine; Medical Director, Saint Barnabas Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Lee P Shulman, MD, Professor of Obstetrics and Gynecology, Head, Section of Reproductive Genetics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.