Ina May's Guide to Breastfeeding

5
Your Baby’s Needs—and Yours—During the First Week

Healthy full-term babies whose mothers have received little or no medication are almost always born wide awake and aware. They prefer rather dim lights to bright ones and their mother’s arms to anyone else’s. Like other newborn mammals, they come equipped with an awareness of their own vulnerability, and they don’t want to be alone. Having spent the entire pregnancy within your body, your baby is going to be comforted by the relaxed loving presence of the most familiar person in the world—you (or her father). She will feel best when she’s being held by you, but she will enjoy being held by another person who loves her if you are not able to hold her right away.

After two or three hours in this state of quiet alertness—characterized by bright, wide-open eyes—your baby may begin to show signs of drows iness and drift off to sleep. In fact, most of her first forty-eight hours will be spent asleep. Three-to four-hour naps are common on the first two days, punctuated by relatively short periods of alert wake-fulness.

A small amount of colostrum will satisfy your healthy full-term baby’s need for liquid for the first two days, so there is no need for her to be given extra nourishment. In fact, giving newborns sugar water at this time can interfere with the initiation of breastfeeding by filling your baby’s tiny stomach, thus taking away her motivation to suckle. She then gets less colostrum and your breasts don’t receive the stimulation they need to get your milk production off to a strong start. If your baby is born between 35 and 39 weeks (the definition of late-preterm), she may look mature, but many of these babies are less vigorous suckers and tend to sleep far more than those who are born at term. They have two to four times the risk for respiratory distress, infection, jaundice, and hospitalization for more than five days. To minimize such risk, it is best to give them supplemental feedings during the first hour or two of life with colostrum you expressed and froze during pregnancy. If your early baby goes right to the breast and is a hearty sucker, this is good. If not, supplement with your colostrum by dropper.

The use of a bottle during the early days of life can interfere with her learning to suck effectively, since the mechanics of receiving milk from an artificial nipple and bottle are so different from drawing milk from your breast. One well-designed study showed that breastfed babies who were given extra water or formula during the first few days actually lost more weight and were slower to start gaining by the fourth day than babies who were exclusively breastfed or formula-fed.1 Late-preterm babies, on the other hand, don’t have these energy reserves. They need early colostrum, as much skin-to-skin contact as possible, and careful assessment of their ability to get your milk. Remember: Some babies appear to be sucking, but they may not be swallowing. If you aren’t sure your baby is actually swallowing, ask the nurse to listen to her throat with a stethoscope as she nurses.

If you have diabetes, then your baby is at risk for hypoglycemia (low blood sugar). It is important that she gets colostrum within the first hour after birth, whether directly from the breast or by supplementation with your expressed colostrum. Over the next three to four hours, nurse or supplement once each hour. Over the next eight hours, try to nurse every two to three hours.

If you are diabetic or obese, it will take longer for your milk to come in, so you should begin to either hand-express or pump right away, as this will reduce any delay in milk production.

Many Babies Aren’t Born Hungry

As previously mentioned, newborn babies almost always lose some weight during the first three to four days of life, whether they are nursed or artificially fed. This is normal. The majority of this weight loss is due to the expulsion of meconium, the odorless substance inside your baby’s intestines during pregnancy that keeps them from sticking together as they develop. When she is born and begins to drink colostrum, a natural laxative, the meconium is expelled; it may weigh as much as half a pound (227 g). Your baby’s weight loss may also be partly from normal fluid loss.

Since most people aren’t aware that a five-to seven-percent loss of a healthy full-term baby’s birth weight is normal during the first days of life, one of the biggest surprises of the first two days is that—though they will want to suck—many babies aren’t born hungry. Nature prepares newborns for birth by filling the liver and other vital organs with enough nutrition in the form of glycogen to sustain the baby for two or three days. True hunger usually arrives on day three or four, around the time that milk production ordinarily begins. Newborn behavior may vary, though, according to how much medication the baby received from drugs given to the mother during labor.

This observation is worth remembering if you have one of those babies who don’t appear to be hungry for the first two days. When mothers get worried about their babies losing weight just after birth, I usually remind them of the 1985 earthquake that struck Mexico City. I remember a report from the rescuers, who, ten days after the earthquake, were still pulling victims from the rubble at the site of a ten-story hospital. During the first week of rescue work, adult survivors were sometimes found alive, but after ten days, the only survivors found were several newborn babies—they were the only humans who had the energy stores to live for such a long time without a drop to eat or drink.

When to Offer Your Breast

Offer your breast to your baby whenever she is in a quiet alert state during the first two days. If she is crying or fussy, relax yourself by breathing slowly and deeply, and calm her by holding her near your breast. These beginning moments together are irreplaceable, and you’ll find that your memories of this time will persist throughout your life, so it’s worth making them as special as they can be.

Don’t take it as rejection if your baby doesn’t spend a lot of time suckling during the first two days of life. Some babies will take the breast only once or twice on the first day but will become more eager to latch on the second or third day. The baby who was such a quiet soul on the first day often shows everyone how many decibels she can reach during the following two. This can be alarming the first time it happens, since the behavior is different from what you’ve seen before. Learn to take a deep, deep breath if you find that your baby’s cry causes you to clench any of your muscles. Do what you feel like to comfort her, whether it’s holding her close, talking to her, or singing to her. These behaviors should help both of you relax.

The Appearance of Colostrum and Milk

Colostrum ranges in color from clear to creamy yellow. Your milk, though, ranges from bluish-white (foremilk) to a whiter color (hind-milk). Sometimes milk turns blue, green, or pink, depending upon what you’ve been eating (food colorings and some foods can affect the color of your milk without harming it).

How to Know That You Are Meeting Your Baby’s Needs

Once your milk comes in, the best way to tell how your baby is doing is to count the number of wet or poopy diapers she gives you. Those babies who are breastfed exclusively don’t pee often during the first day of life; in fact, most pee just once by the end of the first day (some pee as they are being born, but this may not be noted). Most babies make two wet diapers by day two and three on day three of life. It is easier for an inexperienced person to detect a wet diaper if the diaper is cloth rather than an ultra-absorbent disposable diaper, which doesn’t feel wet when it is.

Once your milk begins to come in—usually on day three, four, or five—the number of wet diapers per day will increase dramatically. By the end of the first week, you can tell that your baby is getting enough fluids if she gives you six to eight soaking wet cloth diapers (five or six disposable diapers) within a twenty-four-hour period.

Poop is different. Your baby should poop within twenty-four hours of being born, and she is likely to have several meconium poops during the first two days of life. Meconium is black or greenish-black and sticky, so on days one and two her poop will be like this as well. On days three and four, it will turn several shades lighter and be less sticky as her body expels the remaining meconium and she starts to drink milk. By day four or five, a breastfed baby’s poop will turn yellow, and will no longer be sticky and odorless, because all the meconium will have been expelled. You should be getting three to four of these poopy diapers within a twenty-four-hour period (to count as a poopy diaper, the stained area should be as large as a large grape). Sometimes the poop has an irregular consistency and is curdy, and at other times it can be watery. Regardless of the consistency, it’s almost always yellow. (A grandmother used to formula-fed babies might be surprised at the yellow color, since formula-fed baby poop is usually green, harder than breast-milk poop, and smellier.) If your baby’s poop is still dark and watery by day five and she hasn’t started to gain weight, it may be that you are switching from one breast to the other too soon, causing her to miss out on the more calorie-rich hindmilk. Seek the advice of your knowledgeable lactation consultant or pediatrician.

Besides these signs, you can tell if your baby is suckling well and getting enough milk if:

·         There are all the signs of a good latch.

·         There is movement just in front of your baby’s ears while she is sucking.

·         Nursing feels good to you.

·         When your baby is finished (after ten to twenty minutes), she lets go of your breast.

Your letdown reflex should also be working well. One way to tell is to pay attention to whether your other breast drips or sprays when your baby suckles on one side. You may even find yourself leaking when the usual time for a feeding approaches. (The letdown reflex does not necessarily cause leaking in everyone.) Most women find that they can stop such leaking by pressing directly on the nipple with a forearm or the heel of one hand, or by gently twisting the nipple. A friend of mine leaked so much during the night during the first six months that she took several towels to bed with her to keep her sheets from getting soaked. On the other hand, some women see dripping or spraying only when they are submerged in warm water or leaning forward. You’ll know that your milk is letting down if you experience one or more of the following signs:

·         Milk leaking from the other breast.

·         Tingling in the breasts, with a feeling of overflowing.

·         Uterine cramps.

·         Your baby’s sucking slows during the feeding.

·         You see milk in the corner of your baby’s mouth.

·         You feel more relaxed.

It’s a little more difficult to figure out whether you are meeting your baby’s emotional needs, but it will help you to remember that newborn babies live in the present moment. They don’t think about their experiences; they just experience. When they’re awake, they want to be held or talked to. They want (and will reward) your undivided attention, which means that you need to keep your attention in the present as well. Keeping your attention on your baby is an extremely important way to meet her immediate needs; it will help you learn her cues and eventually be a more confident mother.

Your Baby’s Growth

Your breastfed baby should gain about six ounces per week during the first three or four months, and she should grow about one inch per month. If you give birth in a hospital, your baby will be weighed every day during your stay. This doesn’t mean that it’s necessary for her to be weighed on the first two days after the initial exam, as diaper-counting gives better information. My partners and I usually check the baby’s weight at the age of one week or ten days. If you weigh her at the age of one week, you should figure the weight gain from the lowest weight that she reached. It will take your breastfed baby an average of five to six months to double her birth weight. If she was born prematurely or ill, you can expect that it may take longer for her to reach the normal weight gain.

Skills to Learn During the First Week

Burping

Once your milk comes in and your baby has a full tummy, knowing how to help your baby burp can be a good thing. The time to try is when she has fed for a while and has released your breast. Sit her upright in your lap, supporting her jaw and chest with one hand and gently rubbing and patting her back with your other. Any bubble that’s in her tummy will soon rise to the top. You can also hold her draped over your shoulder with a diaper underneath for protection and pat her back. After a burp, she may want to resume feeding. What if she doesn’t burp after you’ve held her upright for two or three minutes? Don’t worry about it.

Don’t be surprised if your baby spits up milk now and then during the first week. In fact, with some babies, this may go on for four months or so. Spitting up is normal behavior in young babies, and it usually passes by the time they are able to sit up on their own. Lots of babies spit up every day and continue to gain a healthy amount of weight. You can prevent some instances of spitting up by keeping your baby upright just after a feeding and by refraining from putting pressure on her tummy. Avoid dressing her in baby clothes with tight elastic waistbands.

Burp hold

Swaddling

Some babies have trouble taking the breast during the first week or two because they don’t realize that they have to move their hands away from their mouths in order to get a good latch. When you try to move one hand away from her mouth, the other instantly takes its place, and you and your baby soon become too frustrated to connect. Don’t despair. Cultures all over the world have dealt with this problem by passing down the custom of swaddling to successive generations. Swaddling is a way of wrapping the baby tightly in a blanket to calm her. Young babies are used to being in a confined space (your womb), and many feel insecure when they aren’t being held as snugly as they were inside.

Here’s the method I find easiest:

1. Fold one blanket corner down, and lay your baby over that fold. Fold the opposite corner over baby’s arm. 2. Bring baby’s wrapped arm over his or her chest. 3. Tuck the corner snugly under baby’s back. 4. Fold the bottom of the blanket up. 5. Fold the other blanket edge over baby’s free arm, and bring that arm over baby’s chest. 6. Tuck that corner tightly under baby’s back.

I use swaddling mainly to help a jittery or fussy baby take her mother’s breast without frustration. Swaddling is not a good idea if your baby is gaining slowly as it prevents the skin-to-skin contact that will help your baby stimulate a greater milk supply.

Hand Expression

One of the skills you will find extremely useful is hand expression of your milk. It’s a good idea to learn how to do this before you really need it. Many women learn during pregnancy. Your breasts might become overfull when you’re away from your baby; manual expression will probably be the quickest way to feel relieved. Hint: It’s easier to express milk from your breast before rather than after a feeding.

Thumb and finger position for beginning hand expression. Begin with backward motion toward your chest, then roll forward.

Hold your breast with your thumb placed an inch to an inch and a half behind your nipple on the upper side of your breast, and your first two fingers (held close together) at the same distance from your nipple below. Your areola isn’t a good guide for placement, since women’s areolas vary so much in size.

Begin by pressing your thumb and middle finger back toward your chest wall, taking care not to make pressure with your last two fingers on the rest of your breast. Now roll your thumb toward your nipple as if you were making a thumbprint; at the same time, change from middle finger pressure to index finger pressure below. With this motion, you are imitating what your baby’s mouth does while sucking. Repeat this rolling motion rhythmically. You may have to repeat the sequence a few times before your milk begins to flow. Be careful not to squeeze or pull on your breast or nipple.

If you have trouble with this technique, you might find that you have better luck if you are in a shower or a warm bath. It may also help if you roll just behind your nipple gently between your thumb and first two fingers before trying to hand-express milk. Stroke your breast from the chest wall toward your nipple a few times.

Once the milk flow slows or stops, you can rotate your fingers forty-five degrees and then ninety degrees and repeat the process so that you express the milk from all sectors of your breast.

It’s important to remember that hand expression should not hurt. If it does, you are being too rough with yourself. Once you become adept at hand expression, you may find it possible to express from both breasts at once.

Challenges You May Face in Getting Started

More Than Enough Milk

Some women produce much more milk than their babies can swallow. The baby who chokes and pulls away from the breast just when your milk lets down is doing her best not to drown in too much of a good thing. A baby who has trouble dealing with how fast your milk flows will often do better when you are semi-reclined or lying flat with her on top of you. Side-lying can be good as well, as it allows milk to dribble out of her mouth instead of running into the back of her throat and forcing her to gulp fast to keep from choking.

Pay attention to your baby’s head position while feeding, making sure that it’s correct—tilted back slightly with her chin slightly up (not resting on her chest). When her throat is open like this, it is much easier for her to swallow. Allow your baby to pull away whenever she needs to, as you don’t want her to feel that she can’t come away from the breast when the milk is coming too fast. Since she is most likely getting more than enough of the thirst-quenching but less rich foremilk in her feedings, it may be a good idea to put her to feed at the same breast for three or four consecutive sessions so that she will remove enough of the foremilk to get to the richer hindmilk before moving on to the other breast. Fully emptying one breast before introducing the baby to the other will help signal your body to adjust milk production. Please note: This may not be the best strategy if your baby is gaining less than seven ounces per week. When figuring her weight gain, count from her lowest weight, not from the birth weight.

Burp your baby frequently if she seems to take in air while swallowing fast.

The Baby Who Falls Asleep at the Breast

Some babies will suckle a couple of times and then fall asleep while still latched, particularly in the first few days, when the baby is still logy from being born. To keep your baby awake and actively suckling, it may help to stop the feeding, take off all her clothing except for a diaper, massage her feet, walk your fingers up her spine, or tickle her under her chin or behind her neck. Do this, of course, in a warm room. A baby who is hard for Mom to wake up may do so more easily if Dad is the one who stimulates her to drink more. Babies who fall asleep easily at the breast sometimes stay awake better if you make sure that they are very alert before you begin. As your baby gets older, she will be less likely to fall asleep after a few sucks.

A baby who sips, sleeps, and sips like this quickly wears her mother out. It’s best to keep her at the same breast for several feedings, to make sure she’s getting your more-filling hindmilk.

How often should you try to wake your baby at your breast? It depends on whether or not she is swallowing. If she needs to gain weight and she tends to go back to sucking and swallowing when awakened, it’s a good idea to continue the feeding. You may find that compressing your breast manually to quicken your milk flow will suffice to keep your baby awake and drinking. Learn how to time the compressions to the rhythm of her swallowing. Dr. Jack Newman’s website has some excellent clips related to this skill at: http://www.drjackman.com. If you don’t succeed immediately in waking your drowsy baby, perhaps you can both take a wonderful nap—you deserve the rest.

Babies Who Refuse the Breast

Some babies refuse the breast during the first few days after birth. There may be several reasons for this behavior, but the important thing to recognize is that the baby may be quite willing to take the breast at a later time. It’s good not to give up too easily. Of course, it can be frustrating—even frightening—when your baby doesn’t easily latch on to your breast.

Sometimes the problem arises because your baby didn’t get to spend uninterrupted time in skin-to-skin contact with you just after birth. Babies who miss going to the breast during the first hour or two after birth may refuse the breast at first when returned to their mothers’ arms and then seem to have little feeling about what to do with it. Or, if your baby had trouble breathing after birth and was given a deep suctioning or intubation, she may be reacting by drawing her attention away from the part of her body that received the greatest insult—the mouth and throat. This reaction can be strong enough to temporarily override the inborn urge to root and suckle. If either of these is a likely cause for why your baby doesn’t want to accept your breast, the question then becomes how to encourage her normal responses to return. It is necessary to woo your baby with sweet feelings and associations. A good first step is to nuzzle or kiss your baby and then to manually express some colostrum or milk and get it on her lips or tongue. Above all, don’t move quickly or communicate any sense of hurry or urgency. Playfulness and patience are necessary. Talk or sing to your little one, and try to make any time at your breast as pleasant as possible. Calm her before bringing her back to your breast if she becomes upset and starts turning away or arching backward. I know of one father—a farmer—who helped solve his baby’s breast refusal by imitating the behavior he had observed in his nanny goats in similar situations. Like the goats, he tried licking his baby, and it worked. The principles that I have just described are applicable to overcoming breast refusal, no matter what the reason for it may be.

If the breast refusal begins at the end of the first week, the problem may stem from breast engorgement, tongue-tie, or a slow letdown—all of which I discuss in greater detail in the next chapter. Other babies may refuse to latch on if they are sleepy and lethargic because they aren’t getting enough milk (stimulation of the baby’s feet in such a case may encourage her to feed more effectively). It’s also possible that your baby is still feeling the effects of any painkilling medications you were given around the time of her birth.

Ordinarily, there is no reason to wake a sleeping baby. However, if your milk supply seems well established and you are near the end of the first week without getting the number of wet or poopy diapers you need per day, waking your sleepy baby may be worth trying. It will be easier to wake her from a light sleep rather than a deep one, so it’s a good idea to learn to distinguish between the two states. Signs of light sleep are rapid eye movements beneath the eyelids, arm-and leg-twitching, and changes in facial expression; babies in deep sleep no longer move in these ways.

If you decide to wake your baby for nursing, make sure that the room is dimly lit and that you unwrap her from any blankets. Talk to her and try to get eye contact. A gentle massage of her bare feet is one pleasant wake-up technique, and a diaper change is also a good way of waking her. Once your sleepy baby is awake, plenty of skin-to-skin contact, touch, and massage will encourage her to feed. If she gets sleepy at one breast, you might try using the underarm hold rather than the cuddle hold. If sleepiness and lethargy persist throughout the first week, contact a lactation consultant or peer counselor.

Babies, uncivilized little beings that they are, don’t prefer perfume, deodorant, scented lotions, shampoos, or conditioners to the way you happen to smell at any given time. In fact, some babies find these smells so overwhelming (and confusing) that they will not accept the breast when you are wearing a perfumed product. Your baby will love the way you smell even if you happen to be soaked with sweat and spilled milk. This is wonderful, when you think about it.

I have also seen babies refuse the breast during the first two or three weeks because their mothers were taking a DHA supplement that gave their milk a strong, unpleasant taste (not all have an unpleasant taste). Make sure to thoroughly taste any supplements you are taking as well as your own milk to see if this might be a reason for breast refusal.

Babies learn best when they are quickly rewarded for correct behavior. The best reward is your milk, however you can get it into your baby’s mouth. Expressing a few drops before you bring her to your breast is often a good way to encourage her to open wide enough to accept your breast well. If your baby doesn’t open wide and latch when you draw her to your breast, hold her away from your breast for a few seconds (this is better than continuing to hold her so that her lips are touching it, hoping that she will latch correctly next time, as she’s more apt to give up or get mad this way). With a couple of drops on your nipple, draw her to you so that her chin is the first part of her face to touch the underside of your breast. When she gapes wide, hold her close. If she begins suckling, compress your breast with your free hand to start your milk flowing.

If your baby still hasn’t latched well after three or four days, you must contact someone who is experienced at helping babies to latch correctly—for example, a lactation consultant, a midwife, or even another nursing mother. In the meantime, you may need to pump milk and give this expressed milk to your baby via syringe or a supplemental nursing system (SNS) to get enough calories into her. Sometimes, a breast shield can solve the problem.

It will encourage you to know that even if your baby gets off to a slow start with nursing, she can still get the hang of it if you are persistent. I know a mother—Esther—whose baby refused the breast for months before finally starting to nurse.

 Esther: My first two babies were born at home and nursed easily for many months. My third baby, Eric, was born at home three weeks early. He became jaundiced soon after birth, so my midwife wanted him to be checked by a pediatrician. Off we went to the hospital on his second day of life. The residents who saw him scared me with talk about complete blood transfusion, which turned out not to be necessary. With all of the worry and excitement, Eric never managed to latch on, and he became dehydrated. They did a spinal tap on him to try to find out what was wrong, and he was given antibiotics to cover a possible infection (although they never really diagnosed this as his problem). The antibiotics gave him thrush, and that caused nursing to be hard for both of us. He would occasionally manage to get a few swallows of milk, but he wouldn’t stay on very long. It was too much work. He would fuss at me when I would put him to my breast. I would look at him, and he would get yellower as he cried and fussed.

We kept at this for about a week. Nursing him was painful for me. It was very stressful to keep trying while he cried and fussed and then to pump and teaspoon-feed him or try to feed him my milk from a cup. I got so tired in the shoulders that I would just hurt.

Finally I gave up on breastfeeding, because I would show him my breast and he would start to arch his back and cry. My breast had become an unhappy place. But knowing how good breastfeeding is, I gave myself the short-term goal of pumping my milk for six months, so I could feed him my expressed milk. Fortunately, I was good at manually expressing milk.

When Eric was four and a half months old, he began sucking on his fists and making noises. I thought, if you can put both fists in your mouth, try this. He took it on the first try. That day was relatively easy. I was so happy, because it seemed like a miracle. When I called my lactation consultant, she said, “Don’t give him a bottle. Try your hardest, Esther, whatever it takes. Keep offering the breast first.” The next day he was medium about it. On the third day, he got mad and cried a lot, but I kept telling him, “This is it. This is how you get your food.” I put all the bottles out of sight, and I offered him spoonsful of milk a couple of times. After the third day he quit resisting, and there was no more trouble. His best nursing was at night, when we were both half asleep.

Nipple Shields

Sometimes a baby fails to latch well during the first few days because she never manages to get the breast far enough back into her mouth to trigger effective sucking. The thin, soft silicone shields that are now available can often help a baby like this to get a good latch, because the shield can be long enough to reach the part of her mouth that triggers a good suck ling response. The ideal length of the nipple shield would be between two and three cen timeters. A good fit is important, so if a nipple shield doesn’t work for you, the problem may have to do with the size and shape of the shield. If you have trouble getting the shield to stay in place on your breast, it may help to dip it into warm water before applying it.

Nipple shield

Fiona’s story shows how valuable nipple shields can be in teaching some babies a good latch.

 Fiona: When Heather was born, I lost a lot of blood. She didn’t nurse for the first twenty-four hours or so because I was quite weak. After that, it took longer for my milk to come in. I think it was pretty hard for her, waiting for the milk, because she cried a lot and got very irritated every time I tried to put her to my breast. Also, my nipples tend to be sort of flat, which I think added to her frustrations, as she was having trouble latching on.

She latched on successfully only a couple of times during the first few days. My mom said that I had similar problems latching when I was born and that she had used a nipple shield for the first few days. I remember feeling reluctant to try one at first because I was afraid that Heather would get attached to it. The shield helped a lot and allowed Heather to nurse well.

I tried a few times without the shield, but it really made her upset, and she was still struggling to latch on without it. After hearing her hungry cry for so many days, I wanted to do whatever made her happy and just let her nurse with the shield. Periodically I’d try nursing without the shield, but she didn’t seem interested and I didn’t try long.

At around three weeks, I began feeling like I wanted to wean Heather off the shield. I found a forum online where some other women had written about their experience with the shield, and they gave some suggestions of things that had helped in the weaning process.

In the end, it was catching Heather when she was drowsy that did it. She was more willing to try when she was sleepy, and my nipple had been drawn out some at this point, so she had more success latching on. I think it took about a week to wean her completely. She needed the shield less and less until it was just a memory.

Physiologic Jaundice

Good research has shown that babies who breastfeed at least ten times during their first day of life are less likely to develop physiologic jaundice than babies who had fewer feedings. This seems to happen because colostrum has a laxative effect and the excess bilirubin is expelled in the meconium. The baby who gets only a little bit of colostrum will not eliminate the bilirubin so quickly, and this bilirubin can then be reabsorbed into the baby’s blood and cause jaundice.

Don’t worry, though, if your baby doesn’t want to feed ten times on the first day. Many perfectly healthy babies will take two or three days to build up to ten feedings per day, with no negative impact. If they also have signs of physiologic jaundice, it may take a little longer for this jaundice to clear than if the baby was interested in more feedings somewhat earlier.

It’s important to know that jaundice occurs in young babies in more than one form. Physiologic (normal) jaundice is the most common kind, and it is quite harmless. This type of jaundice shows up between day two and day five of life and then subsides, causing no problem to the baby. The more immature the baby, the longer it usually takes for this type of jaundice to disappear. Bilirubin, the yellow pigment that characterizes jaundice, is produced in the liver with the breakdown of old or damaged red blood cells. It must then be excreted by the body. Newborn babies’ livers are still somewhat immature and therefore take a little while to get rid of this excess bilirubin.

Jaundice is usually considered pathologic (a sign of disease) when it is present in the first two days after birth. When this happens, it’s a good idea to have the baby’s blood tested. Other signs of jaundice that may be pathologic rather than physiologic are 1) a deepening of the yellow hue of the skin, 2) when jaundice is present in a baby who is born anemic, 3) when there is a pronounced rise in the baby’s bilirubin level in the days following birth, and 4) when the baby is lethargic.

No matter whether jaundice in a newborn is physiologic or pathologic, breastfeeding should be continued.

Your Own Needs and Feelings

Your needs will be fairly simple during the first two or three days. You’ll be thirsty, hungry, perhaps sore, and you’ll need as much rest as you can get. You will need the help of others. Traditionally, women received care from members of their extended family around this time. Family members prepared food, kept the house clean, looked after older children, and provided any necessary advice and encouragement for breastfeeding. If you have no relative or friend who can help you in this way, good planning can help make the first week or two after birth much easier. Get your grocery shopping done before you give birth, and put plenty of easy-to-prepare food in your freezer. If you can afford to hire a postpartum doula, you may find this kind of help invaluable.

Women who have had relatively short, easy labors sometimes try to resume their normal pace of life on the first few days following birth. Because they feel fit enough to go out to eat or cook a meal for the family, they often can’t think of a good reason to slow their pace. But this expenditure of energy doesn’t contribute to ease in nursing, as would sitting or lying still while holding the baby. I discourage too much activity during the first week or so after giving birth, because your body is going through enormous changes as you make the transition from pregnancy to lactation, and the process works much better when you are resting. Women who try to resume their normal activities during this first week often end up feeling exhausted and depressed. The boost in energy that you may feel after giving birth should be saved, not spent. If your postbirth bleeding slacks off and then gets heavier again, you are probably being too active.

Don’t be surprised if your baby sleeps more in the daytime than at night. Most babies are born with the habit of being awake during the night; this likely has something to do with the fact that when you were asleep during the last weeks of pregnancy, your uterus was more relaxed and thus much roomier than when you were awake. You might as well give in to the idea that this habit isn’t going to change right away and plan accordingly. You will need to learn to sleep when your baby sleeps—both day and night. It may be comforting to know that when you do get a chance to sleep, you probably won’t have any problem doing so as soon as your head hits the pillow. The hormones associated with breastfeeding are the kind that help you fall asleep easily. If you still have trouble sleeping in the daytime, you can try using an eyeshade.

Emotionally, you may feel less than confident and, if your baby is not one of those who latch successfully on the first couple of attempts, you may even feel rejected by her. Will you feel that she doesn’t like you? I hope not, but many women have reported such feelings. Few women today have had a chance to closely observe newborn babies nursing, and this lack keeps them from learning babies’ cues and interpreting what they mean. Because of the invisibility of nursing in our society, many women believe that nursing a baby should be easy and almost automatic or that it is too much trouble to be worth trying. Both of these extreme views are imbalanced and inaccurate; in truth, many women say that the first two to three weeks were very challenging but that they were glad they persisted until they and their babies figured out how to do it right.

Ideally, the first priority of maternity-care policy-making is to make sure that such care truly and comprehensively meets the needs of women and their babies around the time of birth and the sensitive period thereafter. Good maternity care makes it possible for women to concentrate their full attention on their newborn babies, thereby increasing the chance for each mother to have a smooth transition into breastfeeding, reducing levels of postpartum depression, and minimizing chances of illnesses for both mother and baby during the first year following birth. In the Netherlands, the government health plan provides for a specially trained nurse/lactation expert to help each new baby’s parents in their home for a full ten days following each birth (with a small co-payment). Hired for three, five, or eight hours according to individual families’ needs, this maternity nurse serves the new parents breakfast in bed, feeds any older children their breakfast, walks the dog, helps the new mother with breastfeeding if necessary, cleans the house, and notifies the midwife if the mother or baby should need medical attention for any reason. The Dutch consider the care provided each family by the maternity nurse to be an investment in good health, which benefits the entire society because it so effectively reduces the number of illnesses mothers and babies experience during the first year of the baby’s life and thus saves money budgeted for women and children’s care.

Why should women in the United States put up with anything less?