Mayo Clinic Guide to a Healthy Pregnancy: From Doctors Who Are Parents, Too!

CHAPTER 22. Breast-feeding

Do you plan to feed your baby with breast milk or formula? Some women know the answer to this question right away; others struggle.

Clearly, breast milk is best, and the benefits of breast-feeding are well established. Breast milk contains the right balance of nutrients for your baby, and the antibodies in breast milk boost your baby’s immune system to help fight disease. But sometimes breast-feeding isn’t possible. Feeding your baby formula instead of breast milk shouldn’t lead to feelings of guilt. Feeling guilty isn’t good for you or your baby.

For almost every new mom, the first few weeks with a newborn are likely to be demanding and exhausting. Both you and your baby are adapting to an entirely new reality, and that takes time.

Throughout this adjustment, remember that feeding your newborn is about more than just nourishment. It’s a time of cuddling and closeness that helps build the connection between you and your baby. You want to make every feeding a time to bond with your baby. Find a quiet place to feed the child, where you’re both less likely to be distracted. Cherish the time before your baby is old enough to start feeding himself or herself. That time will come soon enough.

5 KEY QUESTIONS

If you’re undecided about breast-feeding, consider these questions:

1. What does your care provider suggest? Your care provider will be very supportive of breast-feeding unless you have specific health issues — such as a certain disease or disease treatment — that make formula-feeding a better choice.

2. Do you have a solid understanding of both methods? Many women have misconceptions about breast-feeding. Learn as much as you can about feeding your baby. Seek out expert advice if needed.

3. Do you plan to return to work? If so, how will that impact breast-feeding? Does your place of work have accommodations available where you can express milk, if that’s your plan?

4. How does your partner feel about the decision? The decision is ultimately yours, but you need to take your partner’s feelings into consideration.

5. How have other mothers you trust and respect made their decisions? If they had it to do over again, would they make the same choices?

BREAST-FEEDING

Breast-feeding is highly encouraged because it has many known health benefits. The longer you breast-feed, the greater the chances that your baby will experience these benefits and the more likely they are to last.

Milk production Breast-feeding is really quite amazing. Early in your pregnancy, your milk-producing (mammary) glands prepare for nursing. By about the sixth month of pregnancy, your breasts are ready to produce milk. In some women, tiny droplets of yellowish fluid (colostrum) appear on the nipples at this time. Protein-rich colostrum is what a breast-fed baby gets the first few days after birth. It’s very good for the baby because it contains infection-fighting antibodies from your body. It doesn’t yet contain milk sugar (lactose).

Your milk supply gradually increases between the third and fifth days after your baby’s birth. Your breasts will be full and sometimes tender. They may feel lumpy or hard as the glands fill with milk. When a baby nurses, breast milk is released from the milk-producing glands and is propelled down milk ducts, which are located just behind the dark circle of tissue that surrounds the nipple (areola). The sucking action of the baby compresses the areola, forcing milk out through tiny openings in the nipple.

Your baby’s sucking stimulates nerve endings in your areola and nipple, sending a message to your brain to release the hormone oxytocin. Oxytocin acts on the milk-producing glands in your breast, causing the ejection of milk to your nursing baby. This release is called the let-down (milk ejection) reflex, which may be accompanied by a tingling sensation.

The let-down reflex makes your milk available to your baby. Although your baby’s sucking is the main stimulus for milk let-down, other stimuli may have the same effect. For example, your baby’s cry — or even thoughts of your baby or the sounds of rippling water — may set things in motion.

Regardless of whether you plan to breast-feed, your body produces milk after you have a baby. If you don’t breast-feed, your milk supply eventually stops. If you do breast-feed, your body’s milk production is based on supply and demand. The more frequently your breast is emptied, the more milk your breasts produce.

Benefits for baby Breast milk provides babies with:

Ideal nutrition Breast milk has just the right nutrients, in just the right amounts, to nourish your baby completely. It contains the fats, proteins, carbohydrates, vitamins and minerals that a baby needs for growth, digestion and brain development. Breast milk is also individualized; the composition of your breast milk changes as your baby grows.

Protection against disease Research shows that breast milk may help keep your baby from getting sick. Breast milk provides antibodies that help your baby’s immune system fight off common childhood illnesses. Breast-fed babies tend to have fewer colds, ear infections and urinary tract infections than do babies who aren’t breast-fed. Breast-fed babies may also have fewer problems with asthma, food allergies and skin conditions, such as eczema. They may be less likely to experience a reduction in the number of red blood cells (anemia). Breast-feeding, research suggests, might also help to protect against sudden infant death syndrome (SIDS), also known as crib death, and it may offer a slight reduction in the risk of childhood leukemia.

Breast milk may even protect against disease long term. As adults, people who were breast-fed may have a lowered risk of heart attack and stroke — due to lower cholesterol levels — and may be less likely to develop diabetes.

Protection against obesity Studies indicate that babies who are breast-fed are less likely to become obese as adults.

Easy digestion Breast milk is easier for babies to digest than is formula or cow’s milk. Because breast milk doesn’t remain in the stomach as long as formula does, breast-fed babies spit up less. They have less gas and less constipation. They also have less diarrhea, because breast milk appears to kill some diarrhea-causing germs and helps a baby’s digestive system grow and function.

Other benefits Nursing at the breast helps promote normal development of your baby’s jaw and facial muscles. It may even help your baby have fewer cavities later in childhood.

Benefits for mother For mothers, the benefits include:

Faster recovery from childbirth The baby’s suckling triggers your body to release oxytocin, a hormone that causes your uterus to contract. This means that the uterus returns to its pre-pregnancy size more quickly after delivery than it does if you use formula.

Suppresses ovulation Breast-feeding delays the return of ovulation and therefore your period, which may help extend the time between pregnancies.

May protect long-term health Breast-feeding may reduce your risk of getting breast cancer before menopause. Breast-feeding also appears to provide some protection from uterine and ovarian cancers.

Pros vs. cons Aside from infant and maternal health, other issues to consider include:

 Convenience. Many mothers find breast-feeding to be more convenient than bottle-feeding. It can be done anywhere, at any time, whenever your baby shows signs of hunger. Plus, no equipment is necessary. Breast milk is always available — and at the perfect temperature. Because you don’t need to prepare a bottle and you can nurse lying down, nighttime feedings may be easier.

 Cost savings. Breast-feeding can save money because you don’t need to buy formula, and you may not need bottles.

 Bonding. Breast-feeding can promote intimacy and closeness between mom and baby. It can be extremely rewarding and fulfilling for you both.

 Rest time for mom. Breast-feeding allows for rest time every few hours while you feed your baby.

Breast-feeding, however, can present some challenges and inconveniences. These may include:

 Exclusive feeding by mom. In the early weeks, parenting can be physically demanding. At first, newborns nurse every two to three hours, day and night. That can be tiring for mom, and dad may feel left out. Eventually, you can express milk with a breast pump, which will enable dad or others to take over some feedings. It may take about a month before your milk production is well established so that you can use a pump to express and collect breast milk.

 Restrictions for mom. Drinking alcohol isn’t recommended for mothers who are breast-feeding, because alcohol can pass through breast milk to the baby. In addition, you may not be able to take certain medications while nursing. Talk to your provider.

 Sore nipples. Some women may experience sore nipples and, at times, breast infections. These can often be avoided with proper positioning and technique. A lactation consultant or your care provider can advise you on proper positioning.

 Other physical side effects. When you’re lactating, your body’s hormones may keep your vagina relatively dry. Using a water-based lubricating jelly can help treat this problem. It may also take time for your menstrual cycle to establish a regular pattern.

WHEN BREAST-FEEDING MAY NOT BE AN OPTION

Almost any woman is physically capable of breast-feeding her baby. The ability to do so has nothing to do with the size of your breasts; small breasts don’t produce less milk than do large breasts. Women who’ve had breast reduction surgery or breast implants may still be able to breast-feed.

In rare situations, a woman may be encouraged to bottle-feed her baby instead of breast-feed. Your care provider may suggest formula-feeding if:

 You’re infected with tuberculosis, HIV, human T-cell lymphotropic virus or hepatitis B or C. These infections can be transmitted to your baby through breast milk.

 You develop West Nile virus or chickenpox (varicella). Breast milk from a woman with these infections could pose a risk to the baby. Recommendations for women with these infections depend on their individual circumstances.

 You drink heavily or use drugs. Breast milk can pass alcohol and other drugs to your baby.

 You’re receiving cancer treatments.

 You’re taking a medication that can pass into your breast milk and might be harmful to the baby, such as anti-thyroid medications, some blood pressure drugs and most sedatives. Before you begin breast-feeding, ask your care provider, your baby’s provider or a lactation consultant about whether you need to discontinue or change any prescription or nonprescription medications you’re taking.

 Your newborn has certain health conditions. Some rare metabolic conditions, such as phenylketonuria (PKU) or galactosemia, may require using specially adapted formulas.

 Your newborn is premature or isn’t growing well. Some infants with poor growth may need to have measured amounts of milk and nutritional supplements. Breast milk may be possible, but you may need to give it by bottle, tube or cup until growth improves.

 Your baby has a mouth deformity, such as a cleft lip or cleft palate. If so, he or she may have difficulty breast-feeding, necessitating that you use a bottle to feed. However, you do have the option of expressing breast milk and putting it in a bottle for your baby.

Vitamin D supplementation If you exclusively or partially feed your infant breast milk, talk to your baby’s doctor about vitamin D supplements for your baby. Breast milk may not provide enough vitamin D, which is essential to help your baby absorb calcium and phosphorus — nutrients necessary for strong bones. In rare cases, too little vitamin D can cause rickets, a softening and weakening of bones.

The American Academy of Pediatrics and the Institute of Medicine recommend that during their first year of life infants receive 400 international units (IU) of vitamin D daily.

Getting started If this is your first experience at breast-feeding, you may be nervous, which is normal. If it goes easily for you right from the first feeding, that’s wonderful. If not, be patient. Starting to breast-feed requires practice. It’s a natural process, but that doesn’t mean it comes easily to all mothers. It’s a new skill for both you and your baby. It may take a few attempts before you and your baby get the hang of it.

The time to begin breast-feeding is right after the baby is born. If feasible, put the baby to your breast in the delivery room. Early skin-to-skin contact has been shown to improve breast-feeding outcomes. Arrange to have your baby in your room at the hospital or birthing center, if possible, to facilitate nursing. To help your baby learn how to breast-feed, request that he or she not be given any supplementary bottles of water or formula. Preferably, baby also shouldn’t receive a pacifier, unless medically necessary, until breast-feeding is well established.

Seek help if you need it While you’re in the hospital, ask your doctor, midwife, nurse or a lactation consultant to assist you. These experts can provide hands-on instruction and helpful hints. After you leave the hospital or birthing center, you might want to arrange for a public health nurse who is knowledgeable about infant feeding to visit you for additional one-on-one instruction. For many reasons, it’s a good idea to take a class on breast-feeding. Often, information on breast-feeding is offered as part of childbirth classes. Or you may need to sign up for a class. Most hospitals and birthing centers offer classes on feeding a newborn.

Have your supplies on hand You’ll want to invest in a couple of nursing bras. They provide important support for lactating breasts. What distinguishes nursing bras from regular bras is that both cups open to the front, usually with a simple maneuver that you can manage unobtrusively while you hold your baby.

You’ll also need nursing pads, which can absorb milk that leaks from your breasts. Slim and disposable, they can be slipped between the breast and bra to soak up milk leakage. Avoid those with plastic shields, which prevent air circulation around the nipples. Nursing pads can be worn continuously or on occasion. Some women don’t bother with the pads, but most women find them helpful.

Try to relax When it’s feeding time, find a quiet location. Have a drink of water or juice at hand because it’s common to feel thirsty when your milk lets down. Put the phone nearby or turn it off. Place a book or the TV remote control within reach, but take advantage if this time with your baby.

Get into a comfortable position Both you and baby should be comfortable. Whether in your hospital bed or a chair, sit up straight. Put a pillow behind the small of your back for support. If you opt for a chair, choose one with low arm rests or place a pillow under your arms for support.

Feeding positions Move your baby across your body so that he or she faces your breast, with his or her mouth near your nipple. Make sure your baby’s whole body is facing you — tummy to tummy — with ear, shoulder and hip in a straight line. Begin by placing your free hand up under your breast to support it for breast-feeding. Support the weight of your breast in your hand while squeezing lightly to point the nipple straight forward.

Different women find different nursing positions most comfortable. Experiment with these positions to see which works best for you:

Cross-cradle hold Bring your baby across the front of your body, tummy to tummy. Hold your baby with the arm opposite to the breast you’re feeding with. Support the back of the baby’s head with your open hand. This hold allows you especially good control as you position your baby to latch on. With your free hand, support your breast from the underside in a U-shaped hold to align with baby’s mouth.

Cross-cradle hold

Cradle hold Cradle your baby in an arm, with your baby’s head resting comfortably in the crook of the elbow on the same side as the breast you’re feeding with. Your forearm supports your baby’s back. Use your free hand to support your breast.

Cradle hold

Football (clutch) hold In this position you hold your baby in much the same way a running back tucks a football under the arm. Hold your baby at your side on one arm, with your elbow bent and your open hand firmly supporting your baby’s head faceup at the level of your breast. Your baby’s torso will rest on your forearm. Put a pillow at your side to support your arm. A chair with broad, low arms works best. With your free hand, support your breast from the underside in a C-shaped hold to align with baby’s mouth. Because the baby isn’t positioned near the abdomen, the football hold is popular among mothers recovering from C-sections. It’s also a frequent choice of women who have large breasts or who are nursing premature or small babies.

Football hold

Side-lying hold Although most new mothers learn to breast-feed in a sitting position, at times you may prefer to nurse while lying down. Use the hand of your lower arm to help keep your baby’s head positioned at your breast. With your upper arm and hand, reach across your body and grasp your breast, touching your nipple to your baby’s lips. After your baby latches on firmly, you can use your lower arm to support your own head and your upper hand and arm to help support your baby.

Side-lying hold

BREAST-FEEDING MULTIPLES

A mother can certainly breast-feed more than one baby. If you have twins, you can breast-feed one baby at a time. Or you can nurse them simultaneously, once breast-feeding is established. To accomplish this feat, you can position both babies in the football (clutch) hold. Or you can cradle them both in front of you with their bodies crossing each other. Use pillows to support the babies’ heads and your arms.

With triplets, it’s possible to breast-feed, although it takes a little more creativity. You might nurse two babies at the same time and give a bottle to the third. At the next feeding, use the bottle for a different baby. The goal is that all three babies have a chance to feed at the breast.

If you’re the parent of multiples, you may want to discuss a breast-feeding plan with your care provider or a lactation consultant before you leave the hospital. Ask them if they know of a mother who has successfully breast-fed her twins or triplets and who would be willing to offer support and practical advice.

Nursing basics If your baby’s mouth doesn’t open immediately to accept your breast, touch the nipple to your baby’s mouth or cheek. If your baby is hungry and interested in nursing, his or her mouth should open. As soon as your baby’s mouth is opened wide, like a yawn, move his or her mouth onto your breast. You want your baby to receive as much nipple and areola as possible. It might take a few attempts before your baby opens his or her mouth wide enough to latch on properly. You can also express some milk, which may encourage baby to latch on.

As your baby starts suckling and your nipple is being stretched in your baby’s mouth, you may feel some surging sensations. After a few suckles, those sensations should subside a bit. If they don’t, sandwich the breast more and draw the baby’s head in more closely. If that doesn’t produce comfort, gently remove the baby from your breast, taking care to release the suction first. To break the suction, gently insert the tip of your finger into the corner of your baby’s mouth. Push your finger slowly between your baby’s gums until you feel the release. Repeat this procedure until your baby has latched on properly. You want your baby to create a firm bond of suction.

You’ll know that milk is flowing and your baby is swallowing if there’s a strong, steady, rhythmic motion visible in your baby’s cheek. If your breast is blocking your baby’s nose, elevating your baby slightly, or angling the baby’s head back and in, may help provide a little breathing room. If your baby attaches and sucks correctly — even if the arrangement feels awkward at first — the position is correct. Once nursing begins, you can relax the supporting arm and pull your baby’s lower body closer to you.

Offer your baby both breasts at each feeding. Allow your baby to end the feeding on the first side. Then, after burping your baby, offer the other side. Alternate starting sides to equalize the stimulation each breast receives.

In general, let your baby nurse as long as he or she wants. The length of feedings may vary considerably. However, on average, most babies nurse for about half an hour, usually divided between both breasts. Ideally, you want the baby to finish one breast at each feeding before switching to the other side. Why? The milk that comes first from your breast, called the foremilk, is rich in protein for growth. But the longer your baby sucks, the more he or she gets the hindmilk, which is rich in calories and fat and therefore helps your baby gain weight and grow. So wait until your baby seems ready to quit before offering him or her your other breast.

Because breast milk is easily digested, breast-fed babies usually are hungry every few hours at first. During those early days, it may seem that all you do is breast-feed! A baby’s need for frequent feeding isn’t a sign that the baby isn’t getting enough; it reflects the easy digestibility of breast milk. If your baby is satisfied after feeding and is growing, you can be confident that you’re doing well.

KEEPING YOURSELF HEALTHY

If you’re like most new mothers, your attention may be focused intently on the needs of your baby. Although this commitment is completely reasonable, don’t forget about your needs. If your baby is to thrive, he or she needs a healthy mother.

Nutrition The best approach to nutrition while breast-feeding isn’t unlike the best approach at other times in your life: Eat a healthy, balanced diet. There are no special foods to avoid when you’re breast-feeding. In addition, drink 6 to 8 cups of fluids each day. Water, milk and juice are good choices. Small amounts of coffee, tea and soft drinks are fine.

As a new mother, it can be hard to prepare healthy meals each day. You may find it easier to snack on healthy foods throughout the day. Partners can help support a breast-feeding mother by bringing her refreshments while she’s nursing.

Rest Try to get rest as a new mother, as hard as that may seem at times. You’ll feel more energetic, you’ll eat better, and you’ll enjoy your new baby best when you’re rested. Rest promotes the production of breast milk by enhancing the production of milk-producing hormones. The soothing effect of breast-feeding can make you feel sleepy, so try and sleep on baby’s schedule.

Don’t be afraid to ask others to help out with daily chores so that you can rest. Younger children may appreciate being able to help out mother and baby by pitching in around the house.

Breast care Once your milk supply is well established and you and your baby are comfortable with breast-feeding, you should be able to work through any problems. However, as you start to breast-feed, you may experience:

Fullness A few days after your baby is born, your breasts may become full, firm and tender, making it challenging for your baby to grasp your nipple. This swelling, called engorgement, also causes congestion within your breasts, which makes your milk flow slower. So even if your baby can latch on, he or she may be less than satisfied with the results.

To manage engorgement, express some milk by hand before trying to breast-feed. Support with one hand the breast you intend to express. With your other hand, gently stroke your breast inward toward your areola. Then place your thumb and forefinger at the top and bottom of the breast just behind the areola. As you gently compress the breast between your fingers, milk should flow or squirt out of the nipple. Taking a warm shower may also result in let-down of milk and provide some engorgement relief. You can also use a breast pump to express some milk.

As you release your milk, you’ll begin to feel your areola and nipple soften. Once enough milk is released, your baby can comfortably latch on and nurse. Frequent, lengthy nursing sessions are the best means to avoid engorgement. Nurse your baby regularly and try not to a miss a feeding. Wearing a nursing bra both day and night will help support engorged breasts and may make you feel more comfortable.

If your breasts are sore after nursing, apply an ice pack to reduce swelling. Some women find that a warm shower relieves breast tenderness. Fortunately, the period of engorgement is usually brief, lasting no more than a few days following delivery.

Sore nipples At the beginning, you may experience some nipple discomfort as baby latches on. This is quite common and is due to tender or cracked nipples. Sore nipples are usually caused by incorrect positioning and latching. At each feeding, you want to make sure that the baby has the areola and not just the nipple in his or her mouth. You also want to be certain that the baby’s head isn’t out of line with his or her body. This position causes pulling at the nipple.

To care for your nipples, express milk onto your nipples and let them air-dry after each feeding. You don’t need to wash your nipples after nursing. There are built-in lubricants around the areola that provide a natural salve. Soap and water with daily bathing is fine. Afterward, let your nipples air-dry.

Blocked milk ducts Sometimes, milk ducts in the breast become clogged, causing milk to back up. Blocked ducts can be felt through the skin as small, tender lumps or larger areas of hardness. Because blocked ducts can lead to an infection, you should treat the problem right away. The best way to open up blocked ducts is to let your baby empty the affected breast, offering that breast first at each feeding. If your baby doesn’t empty the affected breast, express milk from it by hand or by breast pump. It may also help to apply a warm compress before nursing and to massage the affected breast. If the problem doesn’t go away with self-treatment, call a lactation consultant or your care provider for advice.

Breast infection This is a more serious complication of breast-feeding. Infection (mastitis) may be caused by a failure to empty your breasts at feedings. Germs may also gain entry into your milk ducts from cracked nipples and from your baby’s mouth. These germs are not harmful to your baby; everyone has them. They just don’t belong in your breast tissues.

Mastitis starts with flu-like signs and symptoms such as a fever, chills and body aches. Redness, swelling and breast tenderness then follow. If you develop such signs and symptoms, call your care provider. You may need antibiotics, in addition to rest and more fluids. Keep nursing if you’re taking antibiotics. Treatment for mastitis doesn’t harm your baby, and emptying your breasts during feedings will help to prevent clogged milk ducts, another possible source of the condition. If your breasts are really painful, hand express some milk from them as you soak your breasts in a bath of warm water.

Pumping your breasts There may be times when you’re unable to breast-feed and you want to express your breast milk so it can be fed to your baby when you’re away. You can do this either with a breast pump or by hand. However, most breast-feeding mothers find using a breast pump easier than expressing milk manually.

Whether you’re going back to work or simply want the flexibility a breast pump can offer, you’ll have many choices. Ask yourself these questions to decide which type of breast pump — manual or electric — is best for you. If you’re still not sure, ask for help. A lactation consultant or your baby’s care provider can help you make the best choice, and offer help and support if problems arise.

How often will you use the breast pump? If you’ll be away from the baby only occasionally and your milk supply is well established, a simple hand pump may be all you need. These pumps are small and inexpensive. You simply squeeze the handle to express the milk. If you’re returning to work full time or you’re planning to be away from your baby for more than a few hours a day, you may want to invest in an electric pump. Electric pumps stimulate the breasts more effectively than do hand pumps. This helps empty your breasts and protect your milk supply.

Will you need to pump as quickly as possible? A typical pumping session lasts about 15 minutes a breast. If you’ll be pumping at work or in other time-crunched situations, you may want to invest in an electric breast pump that allows you to pump both breasts at once. Double breast pumps can cut pumping time in half.

How much can you afford to spend on the pump? You can purchase breast pumps from medical supply stores, and most drugstores, baby stores, and many discount department stores. While manual models generally cost less than $50, electric pumps that include a carrying case and insulated section for storing milk may cost more than $200. Some hospitals or medical supply stores rent hospital-grade breast pumps, although the equipment that attaches your breast to the pump (pumping kit) must be purchased. Some health insurance plans cover the cost of buying or renting a breast pump. Because there’s a small risk of contamination, borrowing a personal-use pump or buying a used personal-use pump isn’t recommended.

Is the pump easy to assemble and transport? If the breast pump is difficult to assemble, take apart or clean, it’s bound to be frustrating, which may reduce your enthusiasm for pumping. If you’ll be toting the pump to work every day or traveling with the pump, look for a lightweight model. Some breast pumps come in a carrying case with an insulated section for storing expressed milk. Also keep noise level in mind. Some electric models are quieter than others. If it’s important to be discreet, make sure the pump’s noise level is acceptable.

Is the suction adjustable? What’s comfortable for one woman may be un-comfortable for another. Choose a pump that allows you to control the degree of suction. With some manual models, you can adjust the pump handle position.

Are the breast shields the correct size? Every pump has a cone-shaped cup called a shield to place over your breast. If you’re concerned that the standard breast shield is too small, check with individual manufacturers about other options. Larger shields are often available. If you want to pump both breasts at once, make sure the pump is equipped with two breast shields.

Storing breast milk Once you start pumping, it’s important to know how to safely and properly store your expressed breast milk. Consider these do’s and don’ts for breast milk storage.

What kind of container should I use to store expressed breast milk? Store expressed breast milk in capped glass or plastic containers that have been cleaned in a dishwasher or washed in hot, soapy water and thoroughly rinsed. Consider boiling the containers after washing them if the quality of your water supply is questionable.

If you store breast milk for three days or less, you can also use a plastic bag designed for milk collection and storage. While economical, plastic bags aren’t recommended for long-term breast milk storage because they may spill, leak and become contaminated more easily than hard-sided containers. Also, certain components of breast milk may adhere to the soft plastic bags during long-term breast milk storage, which could deprive your baby of essential nutrients.

What’s the best way to store expressed breast milk? You can store expressed breast milk in the refrigerator or freezer.

Using waterproof labels and ink, label each container with the date and time of your contribution. Place the containers in the back of the refrigerator or freezer, where the temperature is the coolest. Use your earliest contribution first.

To minimize waste, fill individual containers with the amount of milk your baby will need for one feeding. Also consider storing smaller portions — 1 to 2 ounces — for unexpected situations or delays in regular feedings. Keep in mind that breast milk expands as it freezes, so don’t fill containers to the brim.

Can I add freshly expressed breast milk to already stored milk? You can add freshly expressed breast milk to refrigerated or frozen milk you expressed earlier in the same day. However, be sure to cool the freshly expressed breast milk in the refrigerator or a cooler with ice packs for at least one hour before adding it to previously chilled milk. Don’t add warm breast milk to frozen breast milk because it will cause the frozen milk to partially thaw. Keep milk expressed on different days in separate containers.

How long does expressed breast milk keep? The length of time you can safely keep expressed breast milk depends on the storage method.

 Milk stored at room temperature. Freshly expressed breast milk can be kept at room temperature — up to 77 F — for four to eight hours. If you won’t use the milk that quickly, store it in the refrigerator or freezer.

 Milk stored in an insulated cooler. Freshly expressed breast milk can be stored in an insulated cooler with ice packs for up to one day. Then use the milk, or transfer the containers to the refrigerator or freezer.

 Milk stored in the refrigerator. Breast milk can be stored in the refrigerator at 39 F for up to eight days.

 Milk stored in the freezer. Breast milk can be stored in a freezer compartment inside the refrigerator at 5 F for two weeks. If your freezer has a separate door and a temperature of 0 F, breast milk can be stored for three to six months. If you have a deep freezer that’s opened infrequently and has a temperature of −4 F, breast milk can be stored for six to 12 months.

The sooner you use the milk, the better. Some research suggests that the longer you store breast milk — whether in the refrigerator or in the freezer — the greater the loss of vitamin C in the milk. Other studies have shown that refrigeration beyond two days may reduce the bacteria-killing properties of breast milk and long-term freezer storage may lower the quality of breast milk’s lipids.

How do I thaw frozen breast milk? Thaw the oldest milk first. Simply place the frozen container in the refrigerator the night before you intend to use it. You can also gently warm the milk by placing it under warm running water or in a bowl of warm water. Avoid letting the water touch the mouth of the container.

Never thaw frozen breast milk at room temperature, which enables bacteria to multiply in the milk. Also, don’t heat a frozen bottle on the stove or in the microwave. These methods can create an uneven distribution of heat and destroy the milk’s antibodies. Use thawed breast milk within 24 hours. Discard any remaining milk. Don’t refreeze thawed or partially thawed breast milk.

Thawed breast milk may smell different from freshly expressed milk or taste soapy due to the breakdown of milk fats, but it’s still safe for your baby to drink.

What else do I need to know about breast milk storage? During storage, expressed breast milk will separate — causing thick, white cream to rise to the top of the container. Before feeding your baby, gently swirl the contents of the container to ensure that the creamy portion of the milk is evenly distributed. Don’t vigorously shake the container or stir the milk. Also be aware that the color of your breast milk may vary, depending on your diet.

Going back to work With a little planning and preparation, you can do both — breast-feed and return to work. Many women do this with the help of a breast pump.

Some mothers work at home, while some arrange to have their babies brought to them for feedings, or they go to the babies. Most mothers, though, use breast pumps to pump their breasts. You can provide your baby with bottled breast milk by expressing milk at work and saving the milk for the next day. Using a double breast pump is the most effective. A double breast pump requires about 15 minutes of pumping every three to four hours. If you need to increase your milk supply, nurse and pump more often.

If you choose not to express your milk while at work, you may pump milk at other times to provide breast milk for the next day. For example, pump after the morning feeding and after the feeding when you return home. As long as all of your milk produced in 24 hours is removed either by your baby or from pumping, you’ll maintain a good supply.

You may decide to have your child care provider give your baby infant formula. This will decrease your milk supply but allow enough to remain for nursing at home. To prevent overly full breasts at work, some mothers find they need to give thawed breast milk or formula to their baby on days off from work at the same times the child care provider feeds the baby.

Once in a while, your baby may take a bottle, then later reject the breast. If this happens, give your baby extra cuddling and attention before feeding.

INTRODUCING A BOTTLE

During the first several weeks of your child’s life, it’s best to nurse exclusively to help you and your baby learn how to breast-feed and to be sure your milk supply becomes well established. Once your milk supply is established and you feel confident that you and your baby are doing well with breast-feeding, you may give your baby an occasional bottle of breast milk. This allows others, such as your partner or a grandparent, an opportunity to feed the baby. If your baby receives a bottle of milk, you may want to pump your breasts for your comfort and to maintain your milk supply.

The feel of a bottle nipple in a baby’s mouth is different from that of the breast. The way a baby sucks from a bottle nipple also is different. It may take practice for your baby to be comfortable with a bottle nipple. A baby may initially be reluctant to take a bottle from mom because he or she associates mother’s voice and scent with breast-feeding.

When you give your baby a supplementary bottle, follow your baby’s cues as to the amount to give. There’s no set amount that’s right. Your baby may be satisfied with a few ounces.

BOTTLE-FEEDING

If you can’t breast-feed or choose not to, be assured that your baby’s nutrition can be met with the use of infant formula.

A wide variety of infant formulas are on the market. The majority of them are based on cow’s milk. However, never use regular cow’s milk as a substitute for formula. Although cow’s milk is used as the foundation for formula, the milk has been changed dramatically to make it safe for babies. It’s treated by heat to make the protein in it more digestible. More milk sugar (lactose) is added to make the concentration similar to that of breast milk, and the fat (butterfat) is removed and replaced with vegetable oils and animal fats that are more easily digested by infants.

Infant formulas contain the right amount of carbohydrates and the right percentages of fats and protein. The Food and Drug Administration monitors the safety of commercially prepared infant formula. Each manufacturer must test each batch of formula to ensure it has the required nutrients and is free of contaminants.

Infant formula is designed to be an energy-dense food. More than half its calories are from fat. Many different types of fatty acids make up that fat. Those that go into infant formula are specifically selected because they’re similar to those found in breast milk. These fatty acids help in the development of your baby’s brain and nervous system, as well as in meeting his or her energy needs.

Pros vs. cons Parents who bottle-feed feel the main advantage of a bottle is:

 Flexibility. Using a bottle with formula allows more than one person to feed the baby. For that reason, some mothers feel they have more freedom when they’re bottle-feeding. Partners may like bottle-feeding because it allows them to share more easily in the feeding responsibilities.

Bottle-feeding can also present some challenges, such as:

 Time-consuming preparation. Bottles must be prepared and warmed for each feeding. You need a steady supply of formula. Bottles and nipples need to be washed. If you go out, you may need to take formula with you.

 Cost. Formula is costly, which is a concern for some parents.

 Formula intolerance. It may take time to find a formula that works well for some infants.

Bottle-feeding basics The first time you purchase infant formula, you may be surprised by how many different types are available. Consult your baby’s care provider for advice about choosing the right formula. For most babies, an iron-fortified, cow’s-milk-based formula is the best choice.

Several special formulas also are available, such as those containing soy protein and protein hydrolysates. These formulas are made for specific digestive problems and should be used only under a care provider’s direction.

Iron-fortified formula is important for preventing anemia and iron deficiency, which can cause slow development. In general, iron deficiency isn’t a risk in the first few months of a baby’s life. However, it can occur later in the first year. Iron deficiency in 6- to 10-month-old infants was common before iron supplementation became routine.

Infant formulas come in three forms: powder, liquid concentrate and ready-to-feed liquid. Both the powder and concentrate liquid formulas must have a specific amount of water added to them. Dry powder formulas generally are the least expensive. Ready-to-feed brands offer great convenience.

If you decide to bottle-feed your baby with infant formula, you’ll need the right supplies on hand when you bring your baby home from the hospital. Let the medical staff assisting your birth know of your plans to bottle-feed. The staff at the hospital or birthing center can provide bottle-feeding equipment and formula during your recovery and show you how to bottle-feed your newborn. But you will still need to stock up on your own supplies.

The equipment needed for bottle-feeding typically includes:

 Four 4-ounce bottles (optional, but useful at the beginning)

 Eight 8-ounce bottles

 Eight to 10 nipples, nipple rings and nipple caps

 A measuring cup

 A bottle brush

 Infant formula

In addition to buying the right equipment, consider taking a class, if you haven’t taken one already. Often, information on feeding a newborn is offered as part of childbirth classes. If you’ve never bottle-fed a baby before, taking a class will help you feel more comfortable when you bring your baby home.

Getting started The bottles for feeding your baby can be glass, plastic or plastic with a soft plastic liner. Bottles generally come in two sizes: 4 ounces and 8 ounces. The amount the bottle holds isn’t an indication of how much your baby needs to drink in a feeding. Your baby may need less or more for any given feeding.

Many types of nipples are on the market, which have openings sized according to a baby’s age. For many babies, it makes little difference which nipples you use. But for a full-term baby, don’t select overly soft nipples designed for use by a premature baby. A full-term baby should use a regular nipple. Use the same kind of nipple for all the bottles.

It’s important that formula flows from the nipple at the correct speed. Milk flow that’s either too fast or too slow can cause your baby to swallow too much air, leading to stomach discomfort and the need for frequent burping. Test the flow of the nipple by turning the bottle upside down and timing the drops. One drop per second is about right.

Nipples come in sizes for a newborn, 3-month-old, 6-month-old, and so on, making the flow rate appropriate for the baby’s age.

Preparing formula Commercial infant formulas are regulated by the Food and Drug Administration (FDA). Three major types are available:

 Cow’s milk formulas. Most infant formula is made with cow’s milk that has been altered to resemble breast milk. This gives the formula the right balance of nutrients and makes the formula easier to digest. Most babies do well on cow’s milk formula. But some babies, such as those allergic to the proteins in cow’s milk, need other types of infant formula.

 Soy-based formulas. Soy-based infant formulas may be an option for babies who are intolerant or allergic to cow’s milk formula or to lactose, a sugar naturally found in cow’s milk. Soy-based formulas can also be useful if you want to exclude animal proteins from your child’s diet. However, babies who are allergic to cow’s milk may also be allergic to soy milk.

 Protein hydrolysate formulas. These are meant for babies who have a family history of milk or soy allergies. Protein hydrolysate formulas are easier to digest and less likely to cause allergic reactions than are other types of formula. They are also called hypoallergenic formulas.

In addition, specialized formulas are available for premature infants and babies who have specific medical conditions.

Whatever type and form of formula you choose, proper preparation and refrigeration are essential, both to ensure the appropriate amount of nutrition and to safeguard the health of your baby.

Wash your hands before handling formula or the equipment used to prepare it. All equipment that you use to measure, mix and store formula should be washed with hot, soapy water and then rinsed and dried before every use. Sterilizing bottles and nipples isn’t necessary as long as you wash and rinse them well. Use a bottle brush to wash bottles. Brush or rub the nipples thoroughly to remove any traces of formula. Rinse well. You can also clean bottles and nipples in the dishwasher.

Whether using powder formula or liquid concentrate formula, always add the exact amount of water specified on the label. Measurements on bottles may be inaccurate, so pre-measure the water before adding it to the formula. Using too much or too little water can be harmful to your baby. If formula is too diluted, your baby won’t get enough nutrition for his or her growth needs and to satisfy his or her hunger. Formula that’s too concentrated puts strain on the baby’s digestive system and kidneys, and could dehydrate your baby. Generally, you can store all prepared formula or liquid concentrate in the refrigerator for up to 48 hours. After that, throw away all unused formula.

Warming formula isn’t necessary for nutritional purposes, but your baby may prefer it warm. To warm formula, set the bottle in a pan of warm water for a few minutes. Shake the bottle and test the temperature of the milk by dropping a few drops of formula on the top of your hand. Don’t microwave formula because this can cause hot spots that can burn your baby’s mouth. Once you warm formula, don’t refrigerate the leftovers. Discard the unused portions of formula.

In general, it’s best to make up formula when you need it, not in advance. However, you may prefer to make up a bottle or two in the evening and store them in the refrigerator for use that night. This can help make night-time feedings easier.

BE FLEXIBLE

Don’t expect your baby to eat the same amount every day. Babies vary in how much they eat, especially if they’re experiencing a growth spurt. At these times, your baby will need and demand more milk and more-frequent feedings. It may seem like your baby can’t get full. During these times, you may need to put your baby to your breast or offer a bottle more often.

Most babies don’t eat at precise intervals throughout the day, as you might first expect. Most babies bunch (cluster) their feedings at various times of the day and night. It’s common for a baby to eat several times within a few hours and then sleep for a few hours.

Getting into position The first step to bottle-feeding is to make you and your baby comfortable. Find a quiet place where you and your baby won’t be distracted. Cradle your baby in one arm, hold the bottle with the other and settle into a comfortable chair, preferably one with broad, low armrests. You may want to put a pillow on your lap under the baby for support. Pull your baby in toward you snugly but not too tightly, cradled in your arm with his or her head raised slightly and resting in the bend of your elbow. This semi-upright position makes swallowing much easier.

Now that you’re ready to start feeding, help your newborn get ready. Using the nipple of the bottle or a finger of the hand holding it, gently stroke your baby’s cheek near the mouth, on the side nearest you. The touch will cause your baby to turn toward you, often with an opened mouth. Then touch the nipple to your baby’s lips or the corner of the mouth. Your baby will open his or her mouth and gradually begin sucking.

When feeding your baby, position the bottle at about a 45-degree angle. This angle keeps the nipple full of milk. Hold the bottle steady as your baby feeds. If your baby falls asleep while bottle-feeding, it may be because he or she has had enough milk, or gas has made your baby full. Take the bottle away, burp your baby, then start to feed again.

Always hold your baby while feeding. Never prop a bottle up against your infant. Propping may cause your baby to vomit and may lead to overeating. In addition, never give a bottle to your baby when he or she is lying on his or her back. This may increase your baby’s risk of developing an ear infection.

Although your baby doesn’t have teeth yet, they’re forming beneath the gums. Don’t develop a habit of putting your baby to bed with a bottle. Formula lingers in the mouth of a baby who falls asleep while sucking a bottle. The prolonged contact of sugar in milk can cause tooth decay.

BREAST OR BOTTLE: FEEDING TIPS

At first, it may seem that all you do is feed your baby. How often you feed your baby depends on how often your baby is hungry, and one feeding may seem to blur right into the next. Breast-fed babies likely will want to be fed between eight and 12 times in 24 hours — about every two to three hours. And formula-fed babies probably will want to be fed between six and nine times in 24 hours — about every three to four hours — for the first few months of life.

Your baby won’t always feed this often. As your baby matures, he or she will gradually need fewer daily feedings and eat more at each feeding. A feeding pattern and routine will begin to emerge after the first month or two. Expect that a newborn will wake routinely one or more times at night for feeding and that your baby may demand more milk during growth spurts.

Feed on cue The size of your infant’s stomach is very small, about the size of his or her fist, and the time it takes to become empty varies from one to three hours. Feeding on cue requires you to watch for signs that a baby is ready to eat: your baby makes sucking movements with his or her mouth or tongue (rooting), sucks on his or her fist, makes small sounds and, of course, cries. The sensation that hunger produces often makes babies cry. You will soon be able to distinguish between cries for food and those for other reasons, such as pain, fatigue, illness. It’s important to feed your baby promptly when he or she signals hunger. This helps your baby learn which kinds of discomfort mean hunger and that hunger can be satisfied by sucking, which brings food. If you don’t respond promptly, your baby may become so upset that trying to feed at this point may prove more frustrating than satisfying.

Let baby set the pace Try not to rush your baby during a feeding. He or she will determine how much and how fast to eat. Many babies, like adults, prefer to eat in a relaxed manner. In fact, it’s normal for an infant to suck, pause, rest, socialize a bit and then return to feeding. Some newborns are speedy, efficient eaters, consistently whizzing through feedings. Other babies are grazers, preferring snack-sized feedings at frequent intervals. Still others, especially newborns, are snoozers. These babies may take a few vigorous sucks and blissfully doze off, then wake, feed and doze again intermittently throughout a typical feeding session.

Your baby will also let you know when he or she has had enough to eat. When your baby is satisfied, he or she will stop sucking, close his or her mouth or turn away from the nipple. Your baby may push the nipple out of his or her mouth with his or her tongue, or your baby may arch his or her back if you try to continue feeding. If, however, your baby needs burping or is in the middle of a bowel movement, his or her mind may not be on eating. Wait a bit and then try offering the breast or bottle again.