Breastfeeding: Getting started

The first weeks of breastfeeding will be a learning period for both you and your baby.

• You can expect to see new changes in your baby's feeding pattern on a daily basis.
• Don't expect to work as a coordinated team immediately.
• Give yourselves plenty of time to recuperate from labor and birth, develop a daily routine, and overcome any initial breastfeeding difficulties.
• It may help to keep a simple checklist chart to mark daily feedings and diaper counts until your baby is gaining weight appropriately.

How is milk made?

• After your baby's birth, a drop in the hormones that maintained the pregnancy occurs and allows the hormone prolactin to begin to work.
• Prolactin tells the breasts it’s time to begin producing large amounts of milk.
• You will feel the result of prolactin when your milk comes in at around three to five days postpartum.
• Increased milk production usually occurs at this time even if your baby has not been breastfeeding well or often. However, frequent breastfeeding sometimes speeds up the process of establishing increased milk production.
• Occasionally, a mother experiences a delay in the production of large amounts of milk.

How much milk is enough?

Long-term milk production depends mostly on milk removal.

• The more often milk is removed (and the more completely it is removed) the more milk the breasts make.
• When milk is removed less often or an insufficient amount is removed, the breasts get the signal to slow milk production and make less.
• Milk removal occurs when your baby effectively breastfeeds. Effective breastfeeding requires effective sucking by your baby so that enough milk is transferred from the breast into your baby’s mouth.
  • Proper sucking signals your body to release the hormone oxytocin, which results in a greater transfer of milk with the milk-ejection reflex (MER), or milk let-down.
• If your baby is not breastfeeding effectively, increased milk removal or production can be accomplished through milk expression techniques.
  • When using manual expression, you compress the milk sinuses by hand to remove milk.
  • Breast pumps remove milk by reducing resistance to milk flow out of the breast, and a few pumps have features that compress milk ducts to some degree.

What to expect when getting started:

Day 1:

• Most full-term, healthy babies are ready and eager to begin breastfeeding within the first half hour to two hours of birth.
• Many babies then sleep or act drowsy for the next two to 20 hours, so your baby may not be very interested in breastfeeding again on his or her birthday.
• Your baby should still breastfeed several times that first day.
• Expect to change only a couple of wet and dirty diapers during the first 24 hours.

Days 2 to 4:

• Although your baby may need practice with latching on and sucking, by the second day he or she should begin to wake and cue (show readiness) for feedings every 1 1/2 to 3 hours for a total of 8 to 12 breastfeedings in 24 hours.
• These frequent feedings provide your baby with antibody-rich first milk called colostrum and tell your breasts to make more milk.
• Your baby should suckle for at least 10 minutes and may continue for about 30 minutes on the first breast before letting go without help from you.
• When your baby finishes at one breast, you can burp and change his or her diaper before offering the second breast.
• As with Day 1, you probably will change only a few wet and dirty diapers on baby's second and third days, and don't be surprised if your baby loses weight during the first several days. The number of diaper changes and baby's weight will increase when your milk "comes in."
• You may feel uterine cramping when breastfeeding the first two or three days, especially if this is a second or subsequent baby. This is a positive sign that the baby's sucking has triggered a milk let-down, also called the milk-ejection reflex (MER). It also means your uterus is contracting, which helps minimize bleeding. A nurse can give you something to take before feeding if needed for the discomfort.
• Some mothers briefly feel a tingling, "pins and needles," or a flushing of warmth or coolness through the breasts with milk let-down; others notice nothing different, except the rhythm of baby's sucking.
• Because your baby still is learning, you may experience nipple tenderness when he or she latches on or during a breastfeeding. Other factors also may contribute to this tenderness, but it's usually mild and disappears by the end of the first week. If tenderness persists, develops into pain or nipple cracking is noted, contact a certified lactation consultant (IBCLC).

Days 3 to 5:

• The volume of breast milk produced increases dramatically at about 3 or 4 days after birth, and the milk is said to have "come in."
• Your baby probably will drift off after his or her 8 to 12, 10 to 30-minute feedings and act more satisfied after a meal.
• Within 12 to 24 hours, you should be changing a lot more wet diapers. The number of dirty diapers also increases, and the stools should be changing in color and consistency. From the dark, tarry meconium stool, they should progress to softer and brown color before becoming a loose and seedy mustard-yellow.
• Weight gain should also pick up within 24 hours of this increase in milk production, so your baby begins to gain at least half an ounce (15 g) a day.
• You may notice that your breasts feel fuller, heavier, or warmer when your milk comes in. Some mothers find their breasts become uncomfortably engorged due to increased milk volume and tissue swelling.
• The breasts feel hard and tight; the areola and nipple may seem stretched and flat, making it difficult for a baby to latch-on.
• The most important thing to do when your milk first comes in is to move the milk out of your breasts by feeding your baby frequently. If your baby has difficulty latching on because of severe engorgement:
  • Soften the nipple and areola by expressing some milk and then let baby latch on.
  • Breastfeed or express milk by hand or breast pump frequently (every one to two hours). Your breasts should feel noticeably softer after breastfeeding or pumping.
  • Apply cold packs or sandwich bags filled with ice or frozen vegetables to the breasts for 20 to 30 minutes after a feeding or pumping session. The application of cold packs has been shown to relieve the swelling that may interfere with milk flow.
  • Some women do report improved milk flow if they also apply warm compresses to the breasts for a few minutes immediately before breastfeeding or milk expression, but there are no studies that support this as effective. Using heat for more than a few minutes could increase the amount of swelling.

Days 5 to 28:

• Your baby will become more proficient at breastfeeding as the first month progresses.
• Expect to feed your baby about 8 to 12 times in 24 hours and for approximately 10 to 30 minutes at the first breast before he or she lets go of the breast without your help.
• You can then burp your baby, change his or her diaper and switch to the second breast. Usually, your baby will breastfeed for a shorter period at the second breast, and sometimes he or she may not want to feed on the second breast at all. Simply offer the second breast first at the next feeding.
• Babies that guzzle their food nonstop may self-detach in 10 to 15 minutes.Babies preferring to savor their meals, often take 20 to 35 minutes on the first breast, because they tend to take a few several-minute breaks between "courses." Whichever type your baby is, it is important to let him or her choose when to let go of the breast, as this self-detachment will increase the amount of higher fat/higher calorie milk ("hindmilk") your baby takes in.

General tips:

• Your baby should continue to:
  • Soak six or more wet diapers daily.
  • Pass three or more loose, seedy, yellow stools daily.
  • Gain more than one half ounce (15 g) a day, more than four to five ounces (120 to 150 g) a week, or one pound (454 g) a month (from lowest weight), regaining birthweight by 2 weeks.
• Your baby probably will go through several two to four day "growth spurt" periods when he or she seems to want to eat almost around the clock.
• Babies commonly experience a growth spurt between 2 to 3 weeks, 4 to 6 weeks and again at about 3 months. It is important to let your baby feed more often during these spurts. Within a few days, your baby will have returned to a more typical pattern.
• Let your baby set the pace for breastfeeding.
• Pay attention to your baby'sfeeding cues.
• The number of feedings each baby needs and the length of time each feeding lasts will vary from baby to baby.
• Trying to force a breastfed baby to wait longer between feedings, or fit a particular feeding schedule, can result in poor weight gain.

Collection and storage of milk:

Milk collection and storage will be a key part of breastfeeding, particularly as you work towards moving your baby towards bottle feeding or prepare to return to work. The following are general guidelines for collecting and safely storing breast milk.

Getting ready:

• Be sure to read the instruction manual for the breast pump and collection kit you are using. For the best compatibility, both items should be manufactured by the same company.
• Breast milk is not sterile, but you do not want to introduce "outside" bacteria when getting ready to pump, during the actual pumping session or when storing or transporting milk.
  • Always wash and rinse your hands thoroughly before handling any clean pump parts, your breasts or the milk collection bottles and containers.
  • Certain pump collection kit parts must be cleaned and sterilized, according to the instruction manual. Most recommend thorough cleaning of these parts after each use and sterilizing parts at least once in 24 hours.
  • The collection bottles and containers that attach to the pump and are used to collect and store your milk should be sterile.
• You may have to experiment with different techniques and settings on your breast pump before you find ones that work best for you. The following are some general tips:
  • Some mothers moisten the rim of the breast flange before pumping to create a better seal on the breast.
  • Some mothers prefer to center the breast flanges on the nipple and areola first and then turn the pump on. Others turn the pump on first and then place the flanges over the breasts.
  • Start the pump at the lowest suction setting and gradually move the setting to increase the level of suction as high as comfort allows.
  • Suction cannot be maintained if the seal of the flange on the breast is broken, so check the seal of the flange periodically. Also watch for the rhythmic pull and release of the nipple and areola within the flange.
  • Expect to pump for a few minutes before you see a steady flow of milk.
  • Do not fill collection bottles more than 2/3 full to avoid any back flow of milk and to allow for expansion if milk is going to be frozen. If you easily fill bottles, have additional collection bottles ready. Stop and change bottles as needed. If your baby takes more than the amount in one bottle at a feeding, you might want to obtain collection bottles that can hold a larger amount.
  • When you are ready to stop pumping, use a clean finger to press in on your breast just above the pump breast flange. This should break the seal between the flange and the breast tissue. If milk has pooled in a flange, tilt it so that milk can drain into the collection bottle as you remove the flange. Then turn off the breast pump. (Some mothers turn the breast pump off first, and then break the seal between the flange and the breast.)

Caring for your breast pump and collection kit:

• Read the instruction manual and follow the recommendations for cleaning pump equipment.
• The pieces of the collection kit come apart for individual cleaning.
• The pump itself and the tubing portion of the kit do not have to be cleaned and should be kept dry or they will not work appropriately. (These pieces never come in contact with milk that is being pumped.)
• After each use, rinse all parts that come in contact with the breast or milk in cool water first. A cool rinse removes residual milk without coagulating hard-to-clean protein. Then thoroughly clean these same parts in hot, soapy water. Rinse in hot water, and air dry between each use.
• Most manufacturers recommend boiling/sterilizing all parts that come in contact with the breast or milk once a day.
• Do not use a dishwasher to clean or sterilize the parts that come in contact with the breast or milk unless the instruction manual suggests this method as an option.

Storing your breast milk:

• Combining milk - If you pumped both breasts at once and the total amount of milk obtained will fill one bottle no more than 2/3 full, you may combine the contents in one bottle by carefully pouring the milk from one sterile container into the other. Do not combine milk from different pumping sessions when pumping for a high-risk baby.
• Label the collection containers immediately. Labels should include the baby's name (if still in the hospital) date, time of day obtained and any medications or substances, such as cigarette by-products that you have taken, or been exposed to since the last pumping session.
• Fresh breast milk contains the most active anti-infective properties. Refrigerated breast milk has fewer anti-infective properties than fresh milk and frozen breast milk has the least.
  • If using unrefrigerated, fresh breast milk, it should be fed to your baby within an hour of being pumped. Do not leave milk out longer than 30 to 60 minutes when it is to be given to a high-risk baby. This risks contamination that a high-risk baby does not need.
  • It's not always possible to give your baby fresh breast milk or you may obtain more than needed for a feeding, so refrigerate any other milk in the labeled collection bottles immediately. The refrigerator should be at a temperature of 32 degrees Fahrenheit to 39 degrees Fahrenheit.
  • Freeze labeled collection bottles if the milk will not be used within 24 to 48 hours.
  • Do not freeze breast milk that has been refrigerated for more than 24 to 48 hours. Although milk has been shown to be safe when refrigerated for several days, experts usually recommend freezing milk sooner when it is to be given to a high-risk baby.
• Milk can be frozen for approximately:
  • two to four weeks if the freezer compartment is within the refrigerator. (You must open the refrigerator door to reach the freezer with this model.)
  • three to four months in a freezer that is part of a refrigerator unit but has a separate door.
  • six (or more) months in a separate, 00 F "deep" freezer.
• To transport refrigerated or frozen milk,place it in an insulated bag or cooler with a cool pack.

Thawing breast milk:

• The oldest milk should be used first, unless recently expressed milk is recommended.
• Thaw breast milk by placing the collection container in the refrigerator. It thaws more quickly when held under warm running water or if it is placed in a cup, pot, bowl or basin of warm water.
• Do not thaw breast milk at room temperature, in very hot water or in the microwave. Microwaving can create hot spots. Both microwaving and heating in very hot water may decrease the amount of certain anti-infective properties in the milk.
• Your milk separates during storage and the cream rises to the top, because breast milk is not homogenized. Gently swirl, or rotate, the collection bottle of milk to mix it together. Avoid vigorous shaking.
• Do not refreeze milk once it has been thawed. Thawed milk must be used within 24 hours for a baby in the hospital and 24 to 48 hours at home.

Breastfeeding and returning to work:

Unless you’re planning to stay home full-time with your baby, most mothers eventually need to deal with the end of maternity leave and a return to work. If your baby hasn’t started taking milk from a bottle, either completely or as a supplement to breast feeding, your return to work will probably require the start of bottle feeding.

How to prepare for your return to work:

• About two weeks before you return to work, start pumping or expressing milk for storage.
  • 
    Start by pumping once a day.
  • Early pumping helps your body learn to "let-down" to a pump, allowing you to store milk that a care provider can feed to your baby in your absence.
  • Many mothers find the best time to pump is in the morning when milk production tends to be greater.
  • Pump approximately one hour after you have breastfed your baby.
  • Slowly increase to two to four pumping sessions per day but, again, feed your baby first.
  • Do not be surprised if your baby wants to breastfeed more frequently for a few days whenever you add a pumping session.
  • You can use the double collection kit to pump both breasts at once, however, some mothers initially pump one breast as the baby breastfeeds at the other. This method has the benefits of double pumping, but may interfere less with baby's breastfeeding routine.
  • A mother's body sometimes learns to let down in response to the pump more easily. If you try this, alternate the breast being pumped as you increase the number of pumping sessions.
  • You still may want to include a few pumping sessions using the double collection kit before you return to work.

What to do when you return to work:

• When you do return to work, plan to get up a little earlier than usual to allow time to breastfeed your baby before leaving for work. Many mothers find they maintain milk production more easily if they breastfeed before showering or getting ready for work and then breastfeed again just before leaving their baby with the care provider. 
• If possible develop a pumping routine based on when your baby would normally breastfeed, especially when first returning to work. You, your baby and your milk production should adjust to a new routine if you are able to pump often enough, but many mothers do find pumping sessions go more quickly when they are able to pump at approximately the same time each day.
• Most mothers prefer to pump both breasts at once with a double collection kit about every three hours, for 10 to 15 minutes. Double pumping minimizes pumping time, but the frequent sessions are needed to "empty" the breasts for continued milk production and to avoid any discomfort. Pumping less frequently, even for longer than 15 minutes, does not help maintain milk production as well.
• If you’re unable to keep a regular pumping schedule at work, expressing small amounts of milk during quick bathroom breaks can help to maintain milk production better than going for longer periods without expressing any milk.
• Don’t pump just prior to leaving work for home (unless you know your baby just ate a big meal). Plan to breastfeed your baby either when you pick him or her up from a care provider or as soon as you get home. Ask your care provider not to feed your baby, or to limit the amount he or she is fed, for one to two hours before you arrive. This will ensure that your baby will still want to breastfeed soon after your arrival.
• You may need to arrange your evening schedule so you can spend more time with your baby when you get home. Breastfeeding more frequently in the evenings and on weekends can help you better maintain milk production, plus you and your baby will enjoy the time together after separation.
• As solid food or other liquids are slowly added to your baby’s diet, you may find you don’t have to pump as frequently to keep up with your older baby's current need for breast milk. However, deleting pumping sessions should be done gradually, one at a time. Once small amounts of solid food are introduced, you may want the care provider to offer it instead of breast milk bottles, so your baby continues to breastfeed more when with you. This also may allow you to begin gradually extending the time between pumping sessions.
• Regardless of when it happens, the first few days or weeks after you return to work may be difficult until you and your baby develop a new routine. You can expect a period of adjustment as your body and your baby respond to the change.
• Some mothers experience a decrease in milk production the first week they return to work due to the stress and changes in schedule. If this does occur, it should quickly resolve itself and milk production should increase with frequent pumping sessions.
• Continue to breastfeed your baby as often as possible when not at work.