Pregnancy, Childbirth, and the Newborn: The Complete Guide, 4th Ed.

CHAPTER 18 Feeding Your Baby

During pregnancy, your body nourishes your baby as he grows from an amazingly tiny fertilized egg to a fully developed newborn who weighs several pounds. After the birth, you continue to nourish him with breast milk, formula, or both. Although either type of nourishment helps your baby triple his birth weight and grow 10 to 12 inches during his first year, only breast milk provides nutrients that encourage the rapid, healthy growth of his brain, nervous and digestive systems, and the development of his immune system.

Whether you feed your baby breast milk or formula, how. you feed him is also important to his growth. The way your baby gets nourishment influences his physical, social, and emotional well-being,1 and feeding him with care and love whenever he shows he’s hungry helps foster his emotional development, encourage bonding, and strengthen family ties.

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In this chapter, you’ll learn about:

• Why experts recommend breastfeeding for your and your baby’s health

• The anatomy of your breasts, how your body makes milk, and how to increase your milk supply

• Positioning your baby so he can latch onto your breast well and feed effectively and comfortably

• Overcoming common breastfeeding challenges and finding breastfeeding help

• Expressing and storing your breast milk

• The basics of formula feeding and bottle-feeding

Breast Milk or Formula?

Whether to feed your baby breast milk or formula (or both) is a personal choice. Before making a decision, it’s important to become well informed about breastfeeding, feeding expressed breast milk by a bottle, and formula feeding. Each method of feeding may have advantages and drawbacks, depending on your unique circumstances.

WHY HEALTH CARE PROVIDERS RECOMMEND BREAST MILK AND BREASTFEEDING

Except in certain rare instances (see page 400), almost all health care providers recommend breastfeeding because of its health benefits for both babies and mothers.

Breast milk’s nutritional composition is ideal for babies. Unlike cow milk and formula, breast milk adapts to meet your baby’s changing nutritional needs. It’s also more easily digestible than the alternatives. Breast milk enhances the development of your baby’s brain and may contribute to a higher IQ and better cognitive test scores.2,3

Babies who are exclusively breastfed for at least three months have fewer and less severe allergies than formula-fed babies.4,5 Breastfed babies are much less likely than formula-fed babies to be hospitalized for infections;6,7overall, they have fewer ear infections, respiratory infections, urinary tract infections (UTIs), and infections from bacterial meningitis. Breastfed babies also have fewer occurrences of diarrhea and vomiting. In addition, studies show that breast milk can lower a baby’s risk of dying from sudden infant death syndrome (SIDS).8,9

Looking ahead to your baby’s future, breastfeeding can reduce the incidence of some diseases that occur later in life, such as insulin-dependent diabetes mellitus, asthma, obesity, leukemia, lymphoma, and multiple sclerosis.10

For you, breastfeeding reduces postpartum bleeding and helps your uterus shrink to its normal size faster. Breastfeeding reduces your risk of some diseases, including premenopausal breast cancer, ovarian cancer, and osteoporosis.11 Studies show that mothers who breastfed have fewer hip fractures after menopause than do women who never breastfed.12

Your family will likely find breastfeeding to be both economical and convenient. (It’s virtually cost free and always available.) It also promotes a close, nurturing relationship between you and your baby.

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IF YOU HAVE CONCERNS ABOUT BREASTFEEDING

Despite health care providers’ endorsement of breastfeeding, you may doubt breastfeeding’s advantages. Maybe you had previous trouble breastfeeding or question its convenience. Perhaps you’re concerned about your ability to breastfeed when you return to work. You may worry that a medical condition will make breastfeeding difficult or harm your breast milk, or you may be pregnant with more than one baby. Your partner may worry that breastfeeding will reduce his or her opportunity to parent.

These concerns may lead you to decide that breastfeeding won’t work for you, but talk to your caregiver, a lactation consultant, your baby’s caregiver, or a childbirth educator about your circumstances before making a decision. You may discover that your concerns about breastfeeding are unfounded or can be addressed.

For example, if you had previous trouble breastfeeding, talk with a lactation consultant during pregnancy to discuss how it can be different this time. If you remain unsure, give breastfeeding a try, knowing that you can stop if it’s unsuccessful.

If you doubt that breastfeeding can be more convenient than formula feeding, talk with families who breastfeed and those who formula feed to get an idea of just how more or less convenient one method is than the other.

Returning to work can present challenges to breastfeeding, but they can be overcome or minimized. See page 431 for further information.

A medical condition can affect breastfeeding. For example, breastfeeding is more difficult for a premature baby or one with a congenital condition such as Down syndrome or cleft palate. A lactation consultant can show you special techniques for feeding a baby with physical challenges. Breastfeeding or providing pumped breast milk can be an excellent way to help your premature or special needs baby grow and stay healthy.

A breast reduction might or might not affect your ability to breastfeed. If you’ve had this surgery, get the support of a lactation consultant before giving birth.

If you’re pregnant with twins, triplets, or more, breastfeeding may be challenging, but even if you can’t always nurse your babies, you can still provide them breast milk by expressing it. See pages 424 and 429 for more information.

If your partner or others worry that breastfeeding will eliminate an opportunity to care for your baby, point out there are many other ways they can actively parent. They can cuddle and soothe your baby; they can bathe her and change her diapers. As your baby grows, her need for social interaction increases dramatically, giving others many occasions to interact with her. For you, a partner or others can provide support and encouragement if difficulties with breastfeeding arise.

After considering your circumstances and concerns, if you decide not to breastfeed, see pages 435–437 to learn about formula feeding. If you want to breastfeed but discover that you can’t, seek the support of your caregiver or a lactation consultant to help you adjust to a different method of feeding.

How to Find a Qualified Lactation Consultant

Lactation consultants are breastfeeding experts who recognize the value of breastfeeding and dedicate their work to its promotion, support, and protection. An International Board Certified Lactation Consultant (IBCLC) is someone who has successfully passed an exam administered by the International Board of Lactation Consultant Examiners (IBLCE). Look for a lactation consultant who has earned these internationally recognized credentials. Here are ways to begin your search:

• Ask your childbirth educator or your local La Leche League group to refer you to an IBCLC.

• If you’re birthing in a hospital, ask your caregiver or nurse whether the hospital has a breastfeeding service that employs lactation consultants.

• Visit http://www.ilca.org, the web site for the International Lactation Consultant Association (ILCA), to find referrals.

If you can’t find an IBCLC, find a nurse trained in breastfeeding support, a doula, midwife, La Leche League Leader, childbirth educator, experienced breastfeeding mom, or another breastfeeding expert in your area to help you.

WHEN HEALTH CARE EXPERTS RECOMMEND FORMULA FEEDING

There are a few cases in which health care providers recommend formula feeding over breastfeeding or breast milk. For example, if a baby has galactosemia (a rare condition in which the baby can’t digest the sugar in breast milk), formula becomes necessary. In most cases, however, the mother’s health is the reason for the recommendation. Formula feeding is best if the mother is HIV positive (and lives in a developed country),1314 has untreated tuberculosis, takes certain medications that may harm the baby (such as lithium or radioactive medications), uses street drugs (such as heroin, cocaine, or methamphetamines), is receiving high doses of methadone, or has had extensive breast surgery.

Some women’s concerns about breastfeeding are psychological. For example, some are overly anxious about nursing in public; others chronically worry that they might not produce enough milk or that breastfeeding may damage their breasts’ appearance. For most women, these concerns are mild and talking with a lactation consultant, obstetrician, or midwife may sufficiently address them. For other women, however, these concerns are overwhelming anxieties, especially if a woman is a survivor of sexual abuse. If you have serious concerns, talking with a lactation consultant or a caregiver can help you decide whether formula feeding is appropriate. If formula feeding is recommended, see page 435 for further information.

CONCERNS ABOUT FORMULA

In the 1980s, the United States Congress enacted and amended the Infant Formula Act, mandating that manufacturers include in their formula at least minimum levels of twenty-nine nutrients and maximum levels of nine nutrients. Despite these regulations, formula doesn’t contain most of the more than two hundred nutrients and components that are present in breast milk. This deficiency may explain why formula can’t (and breast milk can) enhance the development of a baby’s immune system.

Some kinds of formula are less healthful than others. For example, babies fed low-iron formula are more likely to have anemia (which results in lower cognitive test scores) than breastfed babies or babies fed iron-fortified formula.15

Occasionally, manufacturing errors put formula at risk for contamination. When this happens, the formula is recalled, worrying parents whose babies have consumed the recalled formula.

How Breastfeeding Works

Simply explained, breastfeeding is the interaction between you and your baby as he suckles at your breast. Your body began preparing for breastfeeding long before you became pregnant. When you were in your early teens, increasing amounts of the hormone estrogen stimulated the growth of the ductal system within your breasts. The ductal system provides the pathways for milk to flow out of the nipple.

During pregnancy, your breasts prepare for lactation (milk production and secretion) through a complex interplay of hormones that causes rapid growth of the ductal system and the lobular system, which is responsible for milk production. Blood supply to your breasts supports this growth and delivers the nutrients in breast milk.

During the second trimester and as early as the sixteenth week of pregnancy, the hormone prolactin stimulates the production of colostrum (the first milk); the hormone human placental lactogen (HPL) stimulates your breasts to secrete colostrum. After you give birth, progesterone levels fall and prolactin levels increase, triggering breast milk production. These amazing changes occur naturally during pregnancy and the postpartum period.

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ANATOMY OF YOUR BREASTS

Your breasts are well designed to make milk. Each breast contains seven to ten milk-producing units called lobes. Each lobe contains branches of alveoli (cells that make milk) and milk ducts. Milk flows from the alveoli through the ducts and leaves your breast through five to ten nipple openings.16 As your baby compresses the areola (the darker skin around each nipple) with her lips and gums and massages it with her tongue, she draws milk into her mouth. Montgomery glands are the small bumps on the areola that secrete a lubricating substance, which keeps the nipple supple and helps prevent infection. (Use only water to clean your breasts; soap removes this special lubrication.)

Your breasts likely look different during pregnancy. They’re probably larger with more visible veins and stretch marks. Your areolae may appear larger and darker; these changes help your newborn see your nipples. Your Montgomery glands also appear larger. Colostrum may leak from your breasts or dry into a crust on your nipples. These physical changes show that your breasts are responding to pregnancy hormones and preparing to make milk.

Of all women, 2 to 6 percent have accessory mammary tissue, extra breast tissue under the arm or below the breast that may have a nipple.17 This tissue may swell during pregnancy and as milk comes in. If left alone, the tissue diminishes, but placing cold packs on the area may decrease discomfort.

Contrary to popular belief, your breast size doesn’t determine the quality or quantity of the milk you produce. Bigger breasts simply have more fatty tissue surrounding the milk-producing structures than smaller breasts have. Breasts, areolae, and nipples of all sizes and shapes are usually perfect for breastfeeding.

HOW YOUR BODY MAKES BREAST MILK

Prolactin and oxytocin are two hormones that play a significant role in milk production and milk ejection (flow). When your baby suckles at your breast, the action stimulates the anterior pituitary gland in your brain to release prolactin into your bloodstream. Prolactin causes the cells in the alveoli to draw water and nutrients from your blood to make milk. Your baby’s suckling (or even when you hear him cry) also prompts the posterior pituitary gland to release oxytocin. Oxytocin makes the muscles around milk-producing cells contract and expel milk. It also makes the ducts widen and shorten, helping with milk flow. This process is called the let-down reflex or let-down.

You have two or more let-downs from each breast during each feeding.18 During the first weeks after the birth, let-down might not occur until several minutes after your baby has begun suckling. After you and your baby have established a good breastfeeding relationship, let-down occurs within seconds.

Let-down sensations vary widely. During the first few days of breastfeeding, you might not feel your milk let down. Afterward, you still might not feel it, or you might feel a tingling, itching, or flowing sensation. If you don’t feel your milk let-down, you’ll know it has occurred when you hear your baby swallow, see milk in his mouth, or feel uterine cramping.

The frequency and duration of feedings strongly affect your milk supply. The more your baby suckles and drains your breast, the more milk you produce.

Conversely, you may make less milk if you delay or limit feedings, use a pacifier, offer supplements (formula, water, or other liquids), or schedule your baby’s feedings to every three to four hours. The reason is because of a protein in breast milk called feedback inhibitor of lactation (FIL). When your breast is full of milk, FIL slows milk production. When your baby frequently drains your breast, there is less FIL and milk production increases.19

To help develop a good milk supply, feed your baby frequently (that is, in response to his feeding cues—see page 410) and let him feed for as long as he wants.

COMPOSITION OF BREAST MILK

The first milk your breasts produce is colostrum, a yellowish or clear syrupy fluid that’s ideally suited to your newborn’s needs. Colostrum helps speed the passage of meconium (first bowel movement) and establish the proper balance of healthy bacteria in your baby’s digestive tract. Because colostrum is rich in antibodies, it protects your baby from infection. It’s also higher in protein than mature milk. On average, you make just over 1 ounce in the first twenty-four hours after giving birth, which is exactly what your baby needs. The volume of colostrum produced increases over the next few days.20

After making colostrum, your breasts produce transitional milk, which has a yellowish tint and is higher in fat, calories, and volume than colostrum but lower in protein.

Usually by the end of the first week after the birth, you produce mature milk. This bluish white liquid looks like skim milk and contains more calories than colostrum or transitional milk. By the time your mature milk comes is, the volume of milk production has increased substantially. On average, by the fifth day postpartum, you make about 161/2 ounces of milk a day. By three to five months, you make 25 ounces a day; by six months, 27 ounces.21

The composition of mature breast milk varies from the beginning of each feeding to its end. The small amount of milk produced early in the feeding is called foremilk. The larger portion of milk released with let-down is called hindmilk, which provides most of the calories and contains more fat and protein. As your baby grows, the composition of your breast milk changes to meet her nutritional needs.

Components of Breast Milk

Vitamins, minerals, enzymes, hormones, and other components make up breast milk. Here are the main ones:

Nonnutritive qualities

These components protect against disease and promote healthy development. They include anti-infective properties, anti-inflammatory factors, enzymes, hormones, and growth factors.22

Water

About 87 percent of breast milk is water, which helps newborns maintain their body temperature. Even in very warm climates, breast milk contains all the water a baby needs.

Fats

Cholesterol, essential fatty acids, docosahexaenoic acid (DHA), and other fats account for half the calories in breast milk and are necessary for normal development of a baby’s nervous system and brain. Fats also aid visual development and enhance the growth of a special coating on nerves as they grow (myelinization).23

Carbohydrates

Lactose (milk sugar), the primary carbohydrate, helps a baby absorb calcium. It’s metabolized into two simple sugars (galactose and glucose) necessary for rapid brain growth.

Proteins

Whey, the primary protein in breast milk, becomes a soft curd when a baby digests it, letting her bloodstream readily absorb the nutrients. (Casein, the primary protein in cow milk and cow milk formula, forms a rubbery curd that babies digest less easily than whey, sometimes contributing to constipation.)

Vitamins and minerals

Breast milk provides almost all the vitamins and minerals your baby needs. All breastfed babies and some formula-fed babies need to receive vitamin D supplements. A few babies may need iron supplements, and babies at risk of tooth decay may need fluoride.

Iron

A full-term, healthy, breastfed baby rarely needs iron supplementation before six months for two reasons.24 First, iron in breast milk is in a highly absorbable form, despite its small amount. Second, during late pregnancy, a baby stores up iron.

Vitamin D

Vitamin D is essential for your body to absorb calcium. Adequate calcium is necessary for bone growth, the maintenance of bone density, and the normal functioning of your nervous system. A severe deficiency of calcium can lead to rickets, a disease that causes bone deformities. You make vitamin D when you expose your skin to sunlight, or you can obtain it by eating foods supplemented with the vitamin. Because safe levels of sun exposure are difficult to determine and hard to obtain in northern climates, your caregiver may recommend vitamin D supplementation for you or your baby.

A blood test can determine if your levels are adequate. If they are, you don’t need supplements and the amount of vitamin D in your milk meets your baby’s needs. If not, you can take a supplement with 1,000 to 4,000 international units (IU) of vitamin D.25 If you don’t know your level of vitamin D or if it’s inadequate, give your baby liquid vitamin D supplements beginning right after birth. The American Academy of Pediatrics (AAP) recommends that a breastfed baby consume 400 IU of vitamin D daily;26 the Canadian Paediatric Society (CPS) also recommends this amount except for during the winter months, when 800 IU is advised. Choose a supplement that contains only vitamin D; your breastfed baby doesn’t need other vitamins and minerals. (Carlson Baby D Drops and Biotics Bio-D Mulsion are two brands that contain 400 IU of vitamin D in just one drop.)

Fluoride

Fluoride is a mineral that protects against tooth decay. Only small amounts are present in breast milk. The natural water resources in some regions contain fluoride. Some communities add fluoride to their water supply; others don’t. The American Academy of Pediatric Dentistry recommends that parents have a dentist assess their babies’ (or children’s) teeth before giving them supplemental fluoride.27

PRENATAL PREPARATION FOR BREASTFEEDING

To prepare for breastfeeding, learn as much as you can about it before the birth. Read books on the subject, attend a breastfeeding class, and seek the support of groups such as La Leche League, Nursing Mothers Counsel (NMC), new mothers’ groups, or WIC (the U.S. government program for low-income women, infants, and children). Spend time around women who breastfeed so you can see how they nurse their babies and learn how they make breastfeeding part of their busy lives.

Choose caregivers who are committed to supporting breastfeeding. While pregnant, ask your caregiver to assess the changes to your breasts, evaluate your nipples, and look for the presence of scar tissue from biopsies or breast surgeries. Many caregivers haven’t had training to assess breasts for breastfeeding, so you may need a referral to a lactation consultant.

Even if your caregiver is trained in breast assessment, a prenatal visit with a lactation consultant is recommended if you’ve had breast surgeries, are expecting more than one baby, have had a previous unpleasant breastfeeding experience, or have specific concerns about your health, nipples, or breast anatomy. Together, you can determine what steps to take during pregnancy and the postpartum period to create a positive breastfeeding experience.

Arrange for help during the first weeks after the birth. This time is generally the most challenging. Enlist family, friends, or a postpartum doula (see page 27) to help with meals and household tasks so you can focus on feeding and caring for your baby and yourself. Keep the contact information of a lactation consultant and breastfeeding support groups readily available. Lastly, know that with time and experience, breastfeeding becomes much easier, more convenient, and enjoyable.

Nipple Types and Treatment for Flat or Inverted Nipples

There are three main types of nipples.28 Knowing your nipple type lets you know what (if anything) you can do to help make breastfeeding go more smoothly. To determine your nipple type, place your thumb and index finger above and below your areola at its edge and gently squeeze them together under your areola.

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1. Typical nipples elongate or protrude (stick out) when squeezed. They’re the most common type.

2. Flat nipples flatten or move inward (retract) when squeezed.

3. Inverted nipples are tucked into the areola. When squeezed, some protrude while others remain inverted, probably because tiny bands (adhesions) bind the tissue.

If you have flat or inverted nipples, some correction often occurs naturally during pregnancy,29 as hormonal changes enlarge the nipples and improve their ability to protrude. If your nipples remain flat or inverted, you may have trouble starting breastfeeding. In that case, here are a few suggestions:

• Contact a lactation consultant to help with early breastfeeding.

• Consider using a nipple shield, an ultrathin silicone device that you place over your nipple. When your baby sucks on it, he pulls your nipple and milk into his mouth. Don’t use a nipple shield without a lactation consultant’s help; you may need her expert advice to transition to breastfeeding without it.

• Your baby’s sucking also helps evert (draw out) your nipple. But if your baby has difficulty latching on, consider using a breast pump before each feeding to draw out your nipples. A lactation consultant or the maternity nurses can show you how to work the breast pump and may suggest other ideas, such as using commercial “nipple enhancers” designed to draw out nipples. (Evert-it or Avent Niplette are two brands.)

Breastfeeding Basics

If you’ve never breastfed before, the techniques of breastfeeding may seem awkward and difficult at first. With experience, time, guidance, and support, your skills should improve. This section discusses the basics of breastfeeding that can help you create a beautiful relationship between you and your baby.

FIRST FEEDINGS

The first feedings are a special time for you and your baby to get to know each other. Most newborns are alert and interested in feeding or nuzzling in the first hour after birth. Take advantage of this time to establish your milk supply and avoid early breastfeeding problems. Research shows that frequent and unrestricted feedings help prevent engorgement (painful swelling of the breasts) and promote an abundant milk supply.30,31

Two Views on First Feedings

It amazed me that my daughter seemed to know what to do at my breast. It was almost as though she’d practiced for feeding while in the womb. I was surprised by how vigorous her suck was. After the first feeding, we all seemed to relax and rest.

—Kim

My daughter was born by cesarean. Medications from the surgery had made me sleepy for the first feeding, so my husband had to hold her and help her latch on. (At that point, we really wished he’d come to the breastfeeding class with me!) Although we had some problems with bad latch and sore nipples in the beginning, we got the hang of breastfeeding by three weeks.

—Peggy

Here are some tips to make the first feedings a positive experience:

• Breastfeed as soon as possible after the birth.

• Keep your baby with you (preferably skin-to-skin) and let her suckle frequently.

•Try to nurse in a calm, peaceful environment so you and your baby can relax and focus on feeding. If you give birth in a hospital, there may be a lot of distracting activity during the first hour after the birth. (See pages 266–269.) Make sure your caregiver and nurses know (by telling them directly or noting it in your birth plan) that you want to breastfeed your baby as soon after the birth as possible.

If you have a cesarean birth, the completion of the surgery and your recovery may delay the first feeding beyond one hour postpartum. In this case, you need extra help establishing breastfeeding. (See page 428.)

• Don’t hesitate to ask some or all visitors to leave the room. If this idea makes you uncomfortable, have your partner or a nurse ask them to leave.

• Take advantage of the breastfeeding knowledge of experienced staff or your doula. They can offer you invaluable reassurance, encouragement, and support.

BREASTFEEDING POSITIONS

There are several positions for breastfeeding, and each one has special advantages. Whichever position you choose, try to get comfortable and use the basic guidelines in the next paragraph to allow for your baby’s participation in getting a good latch and taking plenty of milk.

Bring your baby to your breast with his nose near your nipple and his ears, shoulders, and hips in a straight line. Nestle him close to your body and support his body from his neck to his hips. When you stabilize his body, he can easily move his head and help with the latch. You can use a pillow to support your arm while feeding.

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Cradle Hold

Cradle your baby’s head in the crook of one arm. Use your forearm to support her body and your hand to support her buttocks.

The advantages of the cradle hold are:

• It’s usually the easiest and most comfortable position for you once your baby is nursing well.

• Many mothers use it after learning to breastfeed, because it’s convenient for a bigger baby.

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Cross-cradle or Alternate Cradle Hold

Hold your baby with the arm opposite of the breast from which you’re feeding, with his tummy against your chest. For example, if your baby is feeding from your right breast, use your left arm to support his trunk. Support his head with your fingers and thumb on the nape of his neck behind his ears. (Don’t press on his head; this may cause him to pull away from your breast.)

The advantages of this hold are:

• Supporting your baby’s neck and shoulders with your hand instead of your forearm allows you and your baby to have more control of his head.

•It’s usually the easiest position to learn how to latch him onto your breast.

•It’s especially helpful for a premature baby or a baby who’s having difficulty latching onto your breast.

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Football or Clutch Hold

Tuck your baby beside your body. Support her body with your arm and cradle the nape of her neck with your fingers and thumb. Bring her up toward your breast as needed so she can easily latch on—she may be lying on her back or side or be sitting up against your chest.

The advantages of this position are:

• It’s easy to see that your baby has latched on effectively.

• It may be the most comfortable if you had a cesarean, because your baby isn’t pressing on your incision.

• It’s helpful if you have large breasts, because your baby’s chest helps support your breast.

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Lying Down

Lie on your side with your lower arm tucked around your baby. (Or you can lie on your side with your lower arm placed under your head.) Lay your baby on his side, tucked alongside your body facing your lower breast. Use pillows for your comfort. To feed from the top breast, lean over slightly to bring your nipple toward your baby’s mouth.

The advantages of this position are:

• It’s easy to rest during feedings.

• It’s comfortable if you have hemorrhoids or are recovering from an episiotomy or tear.

The disadvantages of this position are:

• It often takes practice to learn.

• It may be difficult to see if your baby has latched on well. Have someone check the latch.

Helping Your Baby Latch onto Your Breast

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1. Use a comfortable breastfeeding position. The cross-cradle hold is used in the following example.

2. Hold your baby close to you.

•Have his body touch your chest and his arms near your breast instead of tucked between the two of you. (You may need to lay your other breast over his diaper.)

•Support his head with your fingers and thumb behind his ears—this allows him to move his head, which will help him latch on more easily. (Avoid pressing on the back of his head with your hand.)

•If you lean back with your feet up on a footstool, it’s easy to keep him near you.

3. Bring your baby to your breast. If you hold your breast with your hand, keep your fingers and thumb away from the areola. Allow your breast to remain where it naturally falls and avoid moving it.

4. Help your baby have a good, deep latch.

•Have his nose and upper lip near your nipple.

•Press on his upper back so his head tilts back slightly

•Place his chin on your breast and his lower lip on the outer edge of areola. This encourages him to open his mouth and grasp the areola and nipple

•Wait for him to open his mouth WIDE (as if yawning), then bring his upper lip over the nipple.

5. Indicators that your baby has a deep latch on the breast include:

•His chin indents your breast and his nose is near or barely touching your breast.

•He has more areola in his mouth near his lower jaw, and you see more areola above his lips.

•You hear and see him swallowing—that is, you hear an “ugh” sound and see a pause in suckling.

•After feeding, your nipple should be evenly rounded or the same shape as before feeding. It should not looked compressed or have a ridge in the middle or on one side.

6. Keep your baby close during the feeding.Press on his upper back with your palm, tuck his bottom in close to you, or lean back. Use pillows to support your arm.

If you have trouble getting a good latch when your breasts are very full, use hand expression to make the areola more graspable. Breast pressure or compression can increase the milk flow, to encourage sucking and swallowing. (See pages 420-421.)

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Baby Sitting Upright

Seat your baby on your lap (or on a pillow on your lap) so she faces you and her legs straddle your body. Support her back with your forearm and support the nape of her neck with your hand. Hold your breast with the other hand.

The advantages of this position are:

• It’s easy to see if your baby has a good latch.

• It’s helpful if your baby has gastroesophageal reflux or if you have a very active let-down and a large volume of milk. Sitting upright helps your baby swallow the rapidly flowing milk without difficulty.

CHALLENGES WITH THE LATCH DURING THE FIRST DAYS

Some babies seem to know how to nurse right from birth, while others seem sleepy or uninterested or have difficulty latching on. (See below.)

During the early feedings, your baby may immediately latch onto your breast, tugging and sucking energetically. She may grasp and pull on the nipple so firmly, it surprises you with some discomfort. Or she may tentatively lick and mouth your breast, struggling to get a good latch. Try not to worry if your baby doesn’t nurse on the first try or if every feeding seems to take a lot of work before she latches well. If your baby’s nose was suctioned at birth, she may need time for the stuffiness to clear before latching onto your breast successfully. A long labor can tire babies, and some medications can make them drowsy or uncoordinated. If your baby is drowsy, try the suggestions on page 415 to rouse her.

You, too, may need rest and nourishment to combat the fatigue of a long, difficult labor. In addition, you may have painful uterine contractions (afterpains) when nursing, especially if this baby isn’t your first. Afterpains gradually subside over the first week postpartum, and slow breathing and other relaxation techniques should help you cope in the meantime (see Chapter 11).

Whether your baby nurses well or not, the stimulation of her nuzzling, licking, and closeness to your body encourages milk production. With patience, perseverance, and the help of a knowledgeable lactation consultant or other breastfeeding expert, you and your baby can learn to nurse well.

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WHEN YOUR BABY LATCHES WELL32

When your baby latches effectively onto your breast, she can get the milk she needs easily. Signs of a good latch are usually easy to spot. Just before your baby latches on, she opens her mouth as wide as a yawn, with her tongue down and forward. She then draws your nipple and much of the areola into her mouth, giving her a deep latch. Her chin indents your breast and her nose is close to your breast. Her lips (especially the lower lip) are flanged outward and her tongue is extended over her lower gum.

Your baby begins feeding with short, rapid sucks, her jaw moving rhythmically as she suckles. After the milk has let down, she settles into a slower pattern, with bursts of sucking and short pauses. You can hear her swallow. In the first few days, she may need to suckle five to ten times before she has enough milk to swallow. Once the milk has come in, you can hear her swallow each time she suckles. A swallow may sound like a “huh” rather than a loud gulp.

When Your Baby Doesn’t Latch Well

When your baby doesn’t latch effectively onto your breast, he might not get enough milk and breastfeeding may become difficult. Like the signs of an effective latch, signs of an ineffective latch are easy to spot:

• Your baby’s lips are pursed as though sucking on a straw.

• His cheeks appear sunken, because there’s not enough breast tissue to fill his mouth.

• You hear clicking noises during a feeding.

• You don’t hear him swallow.

• He slips off your breast and roots frantically.

• You feel nipple pain that continues after the first minute of feeding.

To correct an ineffective latch, contact a lactation consultant or other breastfeeding expert for help.

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WHEN TO FEED YOUR BABY

Your baby shows she’s hungry by giving feeding cues. Typical feeding cues include the following:

• Your baby roots toward anything that touches her cheeks or lips.

• She brings her hand toward her mouth.

• She thrusts out her tongue often or makes lots of mouth movements.

• She makes lots of body movements.

• She awakens from a drowsy state.

Most babies show these cues to signal hunger long before beginning to fuss or cry, which are last-ditch attempts to communicate their needs. Trying to feed a crying baby is difficult, so watch for your baby’s feeding cues and promptly feed her whenever she’s hungry.

BURPING YOUR BABY

When your baby feeds (or cries), he may swallow air that travels to his stomach, causing fullness and possible discomfort. Burping releases the swallowed air, and until he can burp on his own (around two weeks old), he needs help doing so. Even after your baby can burp on his own, he still may need help burping if he gulps air.

If breastfeeding, try burping your baby after he’s done nursing at each breast. If bottle-feeding, burp him after he takes two ounces. First, place him in one of the following positions:

• Over-the-shoulder: Place your baby high on your chest with his head peeking over your shoulder. Support him well across his back and buttocks.

• Over-the-lap: Lay your baby on his tummy across your lap.

• Sitting and rocking: Sit your baby on your lap so he faces your side. Place your thumb and index finger under his chin with your palm supporting his chest and your other hand supporting his back. Gently rock him from his front to his back.

Next, gently pat or rub your baby’s back. If after a minute or two he hasn’t burped, stop trying. He doesn’t need to burp.

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WHEN YOUR BABY SPITS UP

During or after feedings, many babies spit up a dribble or more of milk (up to 2 to 3 tablespoons is common). A newborn has an immature sphincter muscle at the top of the stomach, which lets milk and swallowed air back up the esophagus. Spitting up usually isn’t harmful if it occurs only occasionally and the baby is otherwise healthy and growing well. Babies typically outgrow the tendency to spit up around six months old, when they’ve begun to eat solids.

Your baby is more likely to spit up if you have a strong let-down reflex and an abundant milk supply, causing her to eat too much too quickly or swallow air. Try leaning back when nursing or sitting your baby up during feedings, to help her manage the rapid milk flow. (See page 408.) Your baby may also spit up if she cries hard before a feeding.

You can reduce spitting up by burping your baby when she’s done nursing from each breast. (If feeding your baby formula, burp her after every 2 ounces she consumes, and don’t overfeed her.) To keep milk in your baby’s stomach after a feeding, gently position her upright in your arms, on her side if she’s awake, or sitting in a car seat or swing with her head elevated.

If your baby continuously spits up or frequently vomits with force (projectile vomiting), she may have a more serious condition. Call your baby’s caregiver when you see the following signs:

• Your baby seems in pain when spitting up (may be gastroesophageal reflux—see page 380).

• Your baby vomits after every feeding and doesn’t poop frequently.

• Your baby vomits after each of two to three consecutive feedings and seems weak, limp, or lethargic.

Your Baby’s Feeding Patterns

During the first days, weeks, and months of your baby’s life, the frequency and duration of his feedings change to facilitate his growth. Your breasts adapt to these changes to meet his changing needs. This section describes typical feeding patterns of babies.

THE FIRST DAYS AFTER THE BIRTH

After feeding vigorously during the first few hours postpartum, many healthy newborns show little interest in nursing until they’re twenty to twenty-four hours old. By that time, most babies perk up and are eager to nurse again.33However, mothers should keep trying to feed their babies throughout the first day.

As your newborn becomes more awake after the birth, she may want to feed more frequently,34 perhaps in clusters (feeding five or more times in three hours followed by a period of deep sleep) or constantly until your milk comes in. To help ensure your milk comes in soon and in an ample volume, watch for your baby’s feeding cues (see page 410) and feed her as soon as you see these signs. Newborns need to feed at least eight times every twenty-four hours (that is, about once every three hours), but some may feed fifteen to eighteen times during the first days.

Increasing Breastfeeding Success during the First Days

If your baby nurses well soon after the birth, breastfeeding has gotten off to a good start. Watch for your baby’s feeding cues and feed him when he’s hungry, or at least once every three hours.

Babies nurse most vigorously at the first breast offered. Let your baby nurse from the first breast for as long as he likes (ten to thirty minutes on average in the early days). When he detaches from the breast on his own, offer the other breast. (He might or might not take it.) Begin the next feeding with the breast you offered second at the previous feeding. By alternating the breast you offer first, you make sure your baby’s suckling stimulates both breasts to make milk. If you forget which breast to offer first at the next feeding, press your fingertips against your breasts and offer the one that feels most full.

In Their Own Words

At three months old, my daughter didn’t cue for feedings as clearly as she had when she was younger. When she did feed, it was a social event. She’d suck, pull back, smile at me, pat me, suck some more and gaze at me. Feedings took a very long time until I learned to nurse her in a quiet, low-lit (or even dark) place, where she was less distracted.

Tara

If your baby remains with you after the birth, you can watch for his feeding cues and feed him when he wants If your baby spends time in the hospital nursery, you must rely on the nursing staff to let you know when he’s hungry. Request that the staff bring your baby to you for feeding, day or night.

Also make sure to ask the staff not to give your baby any bottles. When full-term, healthy babies breastfeed frequently in response to their feeding cues, they don’t need supple-mental bottles of formula, sugar water, or plain water. In fact, the routine use of supplemental bottles can increase problems with breast feeding by diminishing your baby’s hunger and interfering with his desire to nurse. When your baby spends less time at your breast, your milk supply might not increase enough to meet his needs.

Additionally, sucking on a bottle nipple is entirely different from suckling at a breast. A newborn who feeds from both a bottle and a breast may develop nipple confusion (difficulty adapting to different sucking patterns and differences in flow). If a baby has trouble breastfeeding, he may find feeding from a bottle easier and begin to refuse the breast.35

Pacifiers can also cause problems with breastfeeding in the first days and weeks after the birth. Using pacifiers to delay feedings or to distract your newborn interferes with your development of an adequate milk supply. Pacifiers also may diminish your baby’s interest in feeding by satisfying his need to suck, which may lead to poor weight gain. (See page 414.) Avoid offering your baby a pacifier until after breastfeeding is well established.

If your baby hasn’t nursed well before you’re both discharged from the hospital (or after the first day following a home birth or birth-center birth), get help from a lactation consultant or other breastfeeding expert right away to prevent your baby from becoming dehydrated or losing too much weight.

THE FIRST WEEKS AFTER THE BIRTH

If your baby is nursing frequently, you can expect your milk to come in on the second to fifth day after the birth. When this happens, your body gradually stops making only colostrum and begins to make milk. When your milk comes in, your breasts become heavy, full, and tender. Your nipples may appear flattened because of the swelling. You may begin to seek ways to relieve breast fullness (see page 419).

Once your milk comes in, your baby begins to nurse every one to three hours. As the weeks pass, she consumes more milk at each feeding, which may reduce the number of feedings. She also begins to feed less at night and more during the day and evening. Because babies don’t always nurse on a regular schedule, your baby may cluster her feedings, nursing four to five times in five to six hours and then sleeping for several hours.

THE FIRST MONTHS AFTER THE BIRTH

When your baby is two to three weeks old and has recovered from the birth, he begins to fuss and fret for about an hour (or longer) every evening as a way to cope with new stimulation. During this time, your baby cries, feeds frequently (as often as every thirty to forty minutes), takes brief rests, then cries and feeds again. The frequent nursing stimulates your breasts to make more milk to meet your baby’s greater needs. See page 379 for ways to soothe a fussy baby.

Your baby also may experience similar fussy and challenging stages at ages six weeks, three months, and six months. At these times, babies are acquiring new skills. At three weeks old, your baby awakens to his world. (See page 383.) At about six weeks old, he starts to interact with others by smiling. At three months old, he’s very alert to his surroundings, recognizes one parent from another, and can become easily overstimulated. At about six months old, he masters sitting unaided.

The acquisition of new skills can affect feeding and sleep patterns until your baby masters them. For example, when he’s around three months old, his environment may so distract him that he nurses less frequently during the day, only to wake more at night to feed. Don’t let these changes trouble you. Nursing your baby in a quiet, dimly lit (even dark) place can help him feed more during the day. Usually within a few days to a week, your baby returns to a more predictable feeding pattern.

Making Sure Your Baby Is Getting Enough Breast Milk

By the third or fourth day after the birth, most babies lose from 5 to 8 percent of their birth weight. Once their mothers’ milk is in, babies steadily gain weight. Full-term babies usually regain the weight they lost and return to their birth weight by the tenth to fourteenth day postpartum.

After your milk comes in (around the third to fifth day postpartum), you can watch for the following six signs to ensure that your baby is getting enough of your milk.

Suckles frequently

Your baby feeds vigorously at least eight to twelve times in twenty-four hours.

Swallowing

You hear your baby swallow often. Sometimes during a feeding, he swallows after every suck. Sometimes he sucks a few times before swallowing. He fully extends his jaw when swallowing.

Satisfaction

Your baby seems satisfied after most feedings. Your breast feels softer.

Soaking

For the first week after the birth, expect the number of wet diapers to at least equal the day of your baby’s life (for example, he should wet three or more diapers on day three). After your milk comes in, expect at least six to eight wet cloth diapers in twenty-four hours. Because disposable diapers wick away moisture from your baby’s skin, it’s difficult to tell how often he’s urinating. If using disposables, place a tissue or small piece of paper towel in your baby’s diaper where his urine will wet it.

Stools

After your milk comes in, your baby produces at least three poopy diapers in twenty-four hours. The stools usually are yellow and seedy. For the first month or so after the birth, many babies poop after almost every feeding, or up to twelve times per day. Later on, they usually poop less often.

Signs That Your Baby Isn’t Getting Enough Breast Milk

When your baby doesn’t get enough of your milk, her risk of dehydration or problems with weight gain increase. If you observe any of these signs, schedule an appointment with your baby’s caregiver to have your baby assessed and weighed:

• Your baby feeds fewer than eight times in twenty-four hours.

• After your milk comes in, she doesn’t produce at least one poopy diaper in twenty-four hours.

• She has few wet diapers or produces urine that appears to have reddish “brick dust” in it.

• Your baby seems constantly hungry and is seldom content after feedings.

• Your baby’s feedings worry or concern you.

Some signs are more serious than others. If you notice any of the following signs, call your baby’s caregiver immediately:

• Your baby is lethargic and has no interest in nursing.

• The inside of her mouth doesn’t glisten with moisture. (A baby’s lips can appear dry normally).

• When you gently pinch the skin on her arm, leg, or abdomen and then let go, her skin stays “tented.”

• Her eyes, face, chest, and abdomen are yellow. (See page 416 for more on jaundice symptoms.)

Scales

Your baby should gain 1/2 to 11/2 ounces per day. When he isn’t getting enough milk, other signs besides poor weight gain present themselves. (See above.)

If your baby’s weight doesn’t return to his birth weight ten to fourteen days postpartum, there are two possible explanations:

• Your baby has trouble getting enough milk.

• You might not be producing enough milk and need to take measures to increase your milk supply. (See page 416.)

WHEN YOUR BABY DOESN’T GET ENOUGH MILK

Following are several possible reasons why a baby can’t get enough milk. In some cases, babies are the cause; in others, parents or other caregivers introduce the problem. In still other cases, a medical condition prevents babies from nursing effectively.

Ineffective latch

If a baby can’t latch well onto the breast, she can’t get enough milk. (See page 409.) If you can’t help your baby latch well, get help from a lactation consultant. Most latch problems can be corrected; the sooner you get help, the sooner you can resolve the problem.

Scheduled feedings

Breastfed newborns, especially ones who gain weight slowly, need to feed more frequently than once every three hours. All newborns need to feed at night; feeding shouldn’t be postponed until the morning. Feed your baby whenever she shows an interest in nursing, day or night. (See page 410 for feeding cues.) Let her nurse for as long as she wants.

Feeding from only one breast

If you offer your baby only one breast, you risk inadequate milk production and may limit the amount of milk she gets. Always offer your baby the second breast. For the first week, she may nurse very little from the second breast, but she may want to nurse from both breasts as she grows over the next month or so. When your baby is a month or two old, she may nurse from only one breast at most feedings if you have a good milk supply.

Pacifiers

Giving babies pacifiers can lead to faulty sucking patterns and may shorten the overall duration of breastfeeding.36 If you try to soothe your baby or delay a feeding by giving her a pacifier, she may develop an inability to suckle effectively at the breast, which may slow her weight gain. For breastfeeding success, avoid using pacifiers, especially in the early weeks of breastfeeding.

Sleepy baby

Most parents appreciate a baby who sleeps a lot, but long periods between feedings may prevent your baby from getting enough milk. For the first month after the birth, especially if your baby isn’t gaining weight well, try waking her every two to three hours during the day and every three to four hours at night. If she sleeps so soundly that you simply can’t wake her, wait thirty minutes and try again. Your baby might not get much milk if she’s very drowsy during feedings, pauses for long intervals, or falls asleep even though she spends a long time at the breast. See below for suggestions on how to wake a sleepy baby. If she remains sleepy or lethargic and you can’t get her to nurse, call her caregiver.

Note: After a baby has returned to her birth weight (usually ten to fourteen days postpartum) and is growing well, you don’t need to wake her for feedings.

How to Wake a Sleepy Baby

Once newborn babies are twenty-four hours old, they need to feed at least eight times in a 24-hour period. If your baby doesn’t awaken from a light sleep to feed, try these suggestions to wake him:

• If he’s swaddled, unwrap him. Remove his clothes (leaving just a diaper).

• Dim the lights so he can open his eyes. Talk to him.

• Hold him in a supported standing or sitting position.

• Massage his arms, legs, and chest.

• Rub expressed colostrum or milk onto his lips. Be patient; if he only nuzzles at first, that’s a good start.

• Press on your breast to enhance milk flow and entice him to suckle more vigorously. (See page 421.)

• Burp him (see page 410) or change his diaper.

• Change to another feeding position or switch to your other breast.

After you’ve tried for ten to fifteen minutes to wake your baby, let him sleep in your arms and try again when he starts to waken.

If you continue to have trouble feeding a sleepy baby, get the help of a nurse, lactation consultant, or breastfeeding expert. If your baby isn’t breastfeeding well by twenty-four hours after the birth, ask about using a breast pump to express your milk. Pumping stimulates your breasts to make more milk and ensures that your baby gets your colostrum.

Jaundice

High levels of bilirubin in the blood cause jaundice (see page 389), which causes a yellowish tint on the face, chest, abdomen, and the whites of eyes. If your baby exhibits these signs, call her caregiver. Getting an inadequate amount of milk increases the incidence of jaundice, which sometimes appears in the first two weeks after the birth. Jaundiced babies are often sleepy and uninterested in feeding; this disinterest can further diminish milk intake. Frequent breastfeeding helps relieve jaundice. Avoid giving your baby bottles of water; bilirubin isn’t excreted in urine, and water supplements may reduce the amount of milk your baby consumes. Once jaundice is treated, your baby becomes more interested in feeding.

INADEQUATE MILK SUPPLY

Sometimes, a baby doesn’t get enough milk because his mother isn’t producing enough to meet his current needs. If your milk supply can’t meet your baby’s needs, try the following suggestions:

• Feed frequently, at least eight to twelve times in twenty-four hours.

• Never limit feedings. Let your baby feed for as long as he likes. (Usually ten to thirty minutes at each breast.)

• Make sure that your baby latches well onto your breast and that you can hear him swallow as he suckles. If you don’t, detach him from your breast and have him latch on again.

• To reduce your stress and increase breast stimulation, have a “babymoon.” That is, spend a full twenty-four hours in bed with your baby. Pick a time when you can enlist a postpartum doula (see page 27), family, or friends to help with meals, household chores, and other children so you don’t have to leave the bed except to use the bathroom. Spend the day nursing as often as possible, snuggling skin-to-skin with your baby, eating and drinking well, sleeping, nurturing yourself, and letting others nurture you. Besides helping restore your milk supply and letting you catch up on needed rest, this time of unrestricted nursing can help improve your baby’s weight gain and provide a wonderful opportunity to learn about him.

• Get help from a lactation consultant, who may suggest the following:

* Rent a commercial-grade electric double breast pump. Pump after each feeding for ten to fifteen minutes. (If your baby can’t nurse, you can still build your milk supply by pumping whenever he takes a bottle.)

* If you need to supplement your baby’s feedings, use a syringe or feeding device to feed your expressed breast milk (or prescribed formula) to him through a tube attached to your breast. (See page 426.) This way, your baby receives all his milk from your breast and stimulates it to make more milk.

• Take an herbal medication such as fenugreek, by itself or with blessed thistle, to possibly increase your milk supply. Your lactation consultant or caregiver can tell you how much to take and let you know when you shouldn’t take an herbal medication (for example, if you’re diabetic).

• Take a prescribed medication such as Reglan or Domperidone. The latter isn’t available in U.S. pharmacies, but your lactation consultant can help you obtain it when appropriate. Domperidone has fewer side effects than Reglan, and the American Academy of Pediatrics (AAP) has approved it for nursing mothers.37 Because of the potential risks of Reglan, try using the other measures listed above before taking it.

Common Q & A

Q: My wife is exclusively breastfeeding our son. Is there anything I can do to help?

A: other person provides a breastfeeding mom with extra pairs of eyes, ears, and hands. Sometimes a mom has trouble seeing if the baby is latching onto the breast well. You can help check the latch. As your baby latches onto the breast, you can hold his hands out of the way until he has latched on.

You can also help evaluate how much milk your baby consumes by watching for rhythmic jaw movements and periodic pauses, and listening for swallowing noises that sound like “huh.”

When Your Milk Supply Dwindles

You’ve had an adequate milk supply and your baby has gained weight well, but lately you’ve noticed your milk supply has decreased. What’s the problem? Consider the following possibilities, all of which can reduce your milk supply:

• You’ve begun to take birth control pills containing estrogen.

• You’ve begun using a prescribed estrogen cream to treat vaginal dryness.

• You’ve recently returned to work or another time-consuming activity, which has made you nurse less frequently.

• You’re offering your baby more supplemental bottles and not breastfeeding as often.

• You’re possibly pregnant.

If you can determine the reason for your dwindling milk supply, take the steps on page 416 to increase it. If you don’t produce more milk, seek a lactation consultant for help.

When You Have a Problem with Let-down

Extreme stress, inadequate nipple stimulation, and excessive amounts of alcohol, caffeine, and tobacco may delay or inhibit the let-down reflex.38 To help resolve this problem, try to reduce your stress, give your baby full access to your nipples as she latches onto the breast, and eliminate or limit your intake of alcohol, caffeine, and tobacco. If the let-down reflex continues to give you trouble, contact a lactation consultant for help.

Your Nutrition While Breastfeeding

During pregnancy, your body prepares for lactation by storing 5 to 7 pounds of extra fat to provide some of the extra calories necessary for milk production in the early months. In the first month after the birth, you lose a large amount of the weight you gained during pregnancy, but you may maintain some (or all) of this extra fat for the entire time you breastfeed.

In addition to the stored fat, your body draws on your vitamin and mineral reserves to make milk. Although your body can produce plenty of healthy breast milk regardless of what you eat, eating a poor diet may deplete your nutritional stores over time. Eating poorly also affects your health and your overall well-being.

To maintain your nutritional stores, make sure your diet consists of a variety of healthy foods and includes additional protein (which helps produce milk) and calcium. Many women’s diets don’t include enough calcium, as well as vitamin B, thiamine, folic acid, vitamin D, zinc, and magnesium.39 A diet that’s deficient of these vitamins and minerals reduces a mother’s nutritional stores and poses health risks for both her and her baby.4041 If your diet doesn’t contain adequate amounts of these vitamins and minerals for breastfeeding (see page 403), your caregiver may recommend that you take a vitamin and mineral supplement.

During pregnancy, you may have avoided eating certain foods that might have posed a health risk to your baby, such as soft cheeses, raw fish, and luncheon meats. Happily for you, eating these foods—and generally all foods—doesn’t harm your breast milk and doesn’t harm your baby when he consumes it. An old wives’ tale warns that nursing women should avoid eating cabbage, broccoli, and spicy foods to prevent their babies from developing colic, but there’s no evidence to support this theory. (See page 419 for information on food sensitivity.)

Instead, the foods you eat flavor your breast milk, which benefits your baby by introducing the flavors of foods he’ll eventually eat at the family table. For example, researchers found that babies drank more breast milk when their mothers took garlic capsules.42 Researchers also found that breastfed babies ate peas and beans more readily than did formula-fed babies,43 likely because they recognized the flavors of these vegetables in their mothers’ milk.

Contrary to myth, increasing the volume of fluids you drink doesn’t increase your milk production. Having a well-hydrated body simply keeps you from feeling thirsty and maintains your overall well-being. You know you’re drinking enough fluids when your urine is pale yellow.

What about caffeine? Will a cup or two of coffee affect breast milk? How about a little chocolate (which contains a chemical that’s similar to caffeine)? If you drink caffeinated beverages or eat foods with caffeine, know that less than 1 percent of the caffeine you consume appears in your breast milk. Consuming a serving or two a day doesn’t affect your baby. If, however, you limited caffeine consumption during pregnancy, you may find you’re sensitive to it postpartum.

What about alcohol? When you drink an alcoholic beverage, the concentration of alcohol in your blood approximately equals the alcohol content in your breast milk. This means that the effects of the alcohol on your baby when he consumes your milk corresponds to the amount of alcohol you drank. Although research hasn’t shown that consuming the occasional drink is harmful, it’s generally best to avoid drinking alcohol or drink only occasionally until after your baby is weaned. Researchers found that babies consumed less breast milk after their mothers drank alcohol than did babies whose mothers didn’t drink before nursing.44

If you drink alcohol, consume it in moderation. Don’t drink more than 8 ounces of wine, two beers, or 2 ounces of liquor per day.45 In addition, breastfeed your baby before having a drink. That way, you satisfy his needs and allow time for the reduction or elimination of the alcohol in your bloodstream (and breast milk) before he needs to nurse again.

What about dieting? By three months after the birth, many women have burned the 5 to 7 pounds of fat they acquired during pregnancy for milk production. After you’ve reached your prepregnancy or desired weight, consume enough calories to maintain your weight. Compared to the number of calories you required before pregnancy, you may need only about 300 more calories per day while breastfeeding. (If you’re breastfeeding multiples or a newborn and a toddler, you need more calories.)

If, however, you haven’t shed the extra weight and find those extra pounds frustrating, limit your weight loss to 1 pound per week. Be sure to consume at least 1,500 calories a day and avoid liquid diets and diet medications. Severely restricting calories compromises your nutritional health and may make you produce less breast milk.46

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FOOD SENSITIVITY

In rare cases, a mother eats a food that adversely affects her baby. For example, the baby may become excessively fussy or develop eczema (patches of dry skin), a rash, or diarrhea after consuming breast milk containing protein from certain foods. A baby born into a family with a history of food allergies may react to some of the foods her mother eats. The most common food allergens include cow milk, soy, wheat, eggs, fish, shellfish, and nuts.

If you think a certain food bothers your baby, eliminate it from your diet for a week or so and see if your baby improves. (If you eliminate milk, be sure to get enough calcium from other foods or a supplement.) Discuss your concerns with a lactation consultant or your baby’s caregiver. He or she can help you identify the food causing your baby’s problem and provide you with nutritional guidelines.

Some babies react negatively when their mothers eat large quantities of certain foods. For instance, if you eat an entire bowl of cherries, drink a pitcher of juice, or consume an enormous amount of chocolate, your baby may become fussy or otherwise bothered after nursing. The solution is prevention: Eat all foods in moderation.

Some foods (such as kelp, seaweed, or those containing artificial colors) and vitamin and mineral supplements can tint the color of breast milk, but they don’t pose problems for babies.

Early Breastfeeding Challenges and Solutions

Almost every woman has questions or challenges with breastfeeding in the first months. Some are serious and require more information and assistance, but others are common, predictable, and can be handled easily.

BREAST FULLNESS AND TENDERNESS

When your breasts are full, the best way to relieve the normal discomfort and swelling you experience is to nurse frequently. Full breasts can lead to swollen, flattened nipples and areolae, which your baby may have trouble latching onto. You can soften your nipple and areola by hand-expressing a few drops of milk. (See page 420.) Applying warm packs or standing in a warm shower may also start milk flow, making the areola softer and easier for your baby to latch onto. Once your baby is feeding, press on your breasts (see page 421) to enhance milk flow. Let your baby feed for as long as she wants on the first breast. If she doesn’t feed from the other breast, hand-express or use a pump to reduce fullness in that breast. If your baby can’t nurse even after you’ve expressed milk from your breast, seek a lactation consultant for help and support.

If your breasts are tender after feeding, apply a cool, moist pack or an ice pack to your breasts. If you use an ice pack, first wrap it in a dishtowel or apply it over light clothing. Some women find applying cool cabbage leaves to their swollen breasts reduces tenderness and swelling. Although science hasn’t confirmed the leaves’ effectiveness, they do no harm and may be soothing.47 You may take ibuprofen to reduce discomfort and relieve inflammation.

The fullness and tenderness you experience when your milk comes in is sometimes called engorgement, but these feelings aren’t symptoms of true engorgement, which is a more serious condition caused by unrelieved breast fullness. True engorgement may produce a fever higher than 101°F (38°C), acute continuing breast pain, tingling and numbness in the arm and fingers,48 and difficulty removing milk from the breasts even with a pump. Although the breast fullness and tenderness when milk comes in usually don’t last longer than a day or two and can be relieved by the mother, treating true engorgement may require the help of a lactation consultant.

Softening Your Areola by Hand Expression

To soften your nipples to make them easier for your baby to grasp, follow these steps before he latches on.

1. Place your thumb at the top edge of your areola (where it meets your skin) and your fingers on the bottom edge.

2. Lift your breast with your fingers and thumb. (To keep them from slipping to the end of your nipple, gently press your breast toward your chest with your hand.)

3. Gently squeeze your breast for five to ten seconds. Then move your fingers and thumb to other locations at the edge of your areola. Continue squeezing and pressing your breast against your body until milk releases.

4. Stop when you see a few drops of milk or when the areola is smaller in diameter.

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SORE NIPPLES

Your nipples may become sore any time you breastfeed, but sore nipples are most common during the first weeks. You may have sore nipples only when your baby first latches on, or the soreness may last throughout the entire feeding and between feedings. Sore nipples may cause discomfort or intense pain, but treatment almost always resolves the problem.

For example, a common cause of nipple soreness is overly vigorous or incorrect pumping. To fix this problem, carefully read the information on page 425 about correct pumping. Other common causes for sore nipples include the following.

Early Tenderness

Research shows that most women’s nipples are tender at the beginning of feedings, but the tenderness usually lasts only a few weeks.49 As your baby learns to nurse, his mouth tugs, compresses, and rubs your nipple and areola. The resulting discomfort can make you stiffen in pain and breathe rapidly. As the feeding progresses for thirty seconds or so, the pain lessens or ends. After the feeding, your nipples may appear slightly reddened, bruised, or swollen. To help reduce or prevent early tenderness, hand-express a few drops of milk to soften the areola before feeding, then help your baby latch on well.

Poor Latch

If your nipples remain sore throughout the feeding (and possibly afterward) or they begin to crack and even bleed, a poor latch is likely the cause. A baby might not latch on well if her mothers’ breasts are too full or are engorged, or they have flat or inverted nipples. A baby also may have trouble latching on if she bites instead of suckles, if she tucks her lower lip inward during feedings, or if her mouth is only slightly open (not wide open) and she latches onto only the nipple.

Enhancing Milk Flow with Breast Pressure and Compression

When your breasts are very full, pressing on your breast helps the milk flow toward your nipple. Sometimes called breast massage, this method doesn’t call for you to rub your breast in circles. Instead, you apply breast pressure or compression. With these techniques, you press milk toward the nipple openings and into your baby’s mouth, which prompts a burst of suckling.

Breast pressure

1.  When your baby takes long pauses at the breast or stops suckling, put your palm on your chest near the outer edge of your breast.

2.  Slide your palm on your breast until you feel the firm milk glands.

3.  Press gently from the outer breast toward the nipple. Stop before you get close to the areola. Pressing near the areola can affect your baby’s latch.

4.  When your baby begins to suckle less, move your hand to another part of your breast and repeat these steps.

This technique helps relieve breast fullness, helps empty plugged ducts, and provides more high-calorie hindmilk for your baby.50

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Breast compression

1.  Cup your breast with your hand, placing your thumb and one to two fingers near the outer part of your breast.

2.  Squeeze your finger(s) and thumb together and slightly press into your breast, then out toward your nipple.

3.  When your baby begins to suckle less, cup your breast in another position on the breast and compress it again.

This technique helps babies eat more, especially those who are gaining weight slowly, and entices sleepy babies to continue feeding.

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Premature or ill babies may latch on poorly. A neurological or anatomical condition may prevent otherwise healthy babies from latching on and sucking well. For example, a tight frenulum (“tongue tie”) describes a condition in which the thin membrane that extends from the bottom of the tongue is too short to let the tongue protrude from the mouth.

Having sore nipples because of a poor latch can make you dread breastfeeding. Here are suggestions for prevention and treatment:

• Correct the latch. (See page 409.) Correcting a poor latch relieves most of the soreness instantly, even if your nipple is cracked and bleeding.

• Nurse frequently. If you delay feeding, your breasts become fuller, making it more difficult for your baby to latch on.

• Start on the least sore breast, because babies feed vigorously at the beginning of a feeding.

• To soften the areola and make latching on easier, hand-express some milk before feeding. (See page 420.)

• If you’re sore where your baby’s bottom lip rests on your breast, she may be tucking that lip inward over her gum. Gently pull her lip out when she feeds.

• Before pulling your baby from the breast to reposition her, first slip your finger into her mouth and break the suction so your nipple comes out easily.

• If you use nursing pads, change them whenever they become wet.

• Take a pain relief medication, such as ibuprofen.

• See a lactation consultant. This professional can help you with your baby’s latch and suggest treatments that promote healing. She may recommend using a nipple shield during feedings to protect your nipple, help with the latch, and encourage a flat nipple to protrude. She may suggest using special nipple creams or a hydrogel dressing (a gel-like pad that may increase comfort and speed healing). If infection or allergy may be the cause, she may encourage you to see your caregiver, a physician specializing in breastfeeding medicine, or a dermatologist. If a tight frenulum is interfering with breastfeeding, she may refer your baby to a physician skilled in breastfeeding medicine, who may suggest clipping the frenulum (a minor procedure) to free the baby’s tongue and solve the latch problem.

Advice from the Authors

When you have breastfeeding questions, concerns, or need extra encouragement, consider these sources of support:

• Your caregiver or your baby’s caregiver

• Hospital staff (Ask if they have a breastfeeding hotline or if it’s okay to call the labor and delivery unit with questions.)

• Lactation consultant

• Physician specializing in breastfeeding medicine

• La Leche League group or any new moms’ support group

• Someone who has successfully breastfed her baby

• National Women’s Health Center: http://www.womenshealth.gov/

• Web sites on breastfeeding support, including http://www.womenshealth.gov/breastfeedinghttp://www.llli.orghttp://www.breastfeeding.com, and http://www.breastfeedingonline.com

• Online forums on breastfeeding, including http://forums.llli.org/http://www.mothering.com/discussions/, and http://www.kellymom.com

Infection

Persistently sore breasts or nipples (often cracked and bleeding) are typically the result of a bacterial infection (most often Staphylococcus aureus), a fungal (yeast) infection, or a herpes infection.

If the infection is herpes, you must discontinue breastfeeding on that breast until the herpes sore heals.

To determine whether the infection is bacterial, physicians take a culture of the area. If the infection is bacterial, physicians may prescribe a topical antibiotic cream or suggest using a combination cream to treat bacterial and yeast infections and reduce inflammation. They occasionally recommend oral antibiotics.

Yeast infections cause soreness less often than other infections. If you have a yeast infection, your nipples may look dark pink, shiny, and irritated, or they may look normal. Small blisters may appear. Antibiotic therapy often precedes yeast infections, and a vaginal yeast infection can lead to a yeast infection of the nipples. Yeast infections also occur when a baby has a yeast diaper rash or has a yeast infection of the mouth (thrush).

For a yeast infection, both you and your baby need treatment. Consult with your caregiver or a lactation with consultant for suggestions. Eating yogurt is one home remedy you may try, either by itself or in combination with other treatments. Be sure the yogurt contains live cultures, particularly acidophilus and bifidus, to restore the delicate balance of microorganisms in your body. Stress or antibiotic use can upset this balance and cause an overgrowth of yeast. Experts haven’t determined just how much yogurt you should eat to see improvement or a cure, but it doesn’t harm you to eat a comfortable amount.51 If you don’t care for yogurt, consider taking acidophilus pills or probiotics.

Your caregiver also may prescribe an oral medication for you and may suggest using a topical over-the-counter anti-fungal cream to treat your nipples and your baby’s diaper rash. Your baby’s caregiver may prescribe a liquid medication, such as nystatin suspension, to apply to your baby’s mouth. If these treatments don’t work, your lactation consultant can suggest other treatment options.

BREAST PAIN CAUSED BY LET-DOWN

At the beginning of a feeding, some women experience a sharp, deep pain behind the areola that subsides when the milk begins to flow. This pain doesn’t indicate a problem and usually disappears over time without treatment. Oxytocin is probably the cause; the release of this hormone shortens and widens the ducts, thereby increasing pressure as milk flows through them. If you had breast surgery, let-down may stretch scar tissue and cause pain. Slow breathing may help relieve pain (see page 224).

LEAKING

During the first few weeks or months of breastfeeding, your breasts may leak milk. As your breasts “learn” how much milk to make and when to let down, the leaking usually subsides. Leaking typically occurs when your breasts are very full, when you hear your baby cry, or when you’re sexually aroused. Here are some suggestions for preventing or minimizing leaking:

• When you start to feel your milk let down, discreetly press your hands or forearms firmly against your breasts to slow the milk flow.

• Compress your nipple between your thumb and index finger to stop the flow.

• To prevent soaking your clothes, wear washable cotton or wool nursing pads or disposable pads and change them when they become damp. Avoid using nursing pads with plastic liners; they retain moisture, which contributes to nipple soreness. Some mothers like using silicone pads that exert gentle pressure over the areolae to stop leaking. (Lilypadz is a popular brand.)

PLUGGED DUCTS

If your breast gradually develops a tender, swollen lump or a sore area (but you don’t have a fever), you probably have a plugged duct. The area near the plugged duct may be reddened. These suggestions help relieve discomfort:

• Apply a warm, moist washcloth to the sore area before and during feedings.

• Feed from the sore breast first.

• Press from behind the sore area toward the nipple during feedings. (See page 421.)

• Nurse your baby in a different position so his mouth puts pressure on different places on the breast.

• While showering, massage your breast, pressing from the plugged duct toward the nipple.

• Avoid wearing poorly fitting bras; they may obstruct milk ducts. Also, check the fit of your baby carrier. Some carriers’ straps press on your breasts and affect milk flow.

• Pay attention when using a breast pump. Pressing the flange unevenly on your breast can reduce milk flow in one area.

It may take a few days to clear a plugged duct, but have your caregiver evaluate any lump that doesn’t disappear within a week or two.

MASTITIS

Mastitis is an infection of the breast that appears suddenly and can occur any time while you’re nursing. Besides a tender, reddened breast, symptoms include fever, chills, fatigue, headache, and sometimes nausea and vomiting. Health care providers consider these flu-like symptoms in a breastfeeding woman to be mastitis until proven otherwise. If you have these symptoms, call your caregiver. He or she may prescribe antibiotics and advise you to do the following:

• Continue to nurse from both breasts. The milk isn’t infected and doesn’t harm your baby.

• Take all the prescribed antibiotics. If you stop taking the antibiotics when you start to feel better, the infection will return.

• Rest in bed until you feel better. Drink plenty of fluids.

• Apply a warm, wet washcloth on the painful area to help increase blood circulation to the breast.

• Take ibuprofen or acetaminophen to reduce fever, pain, and inflammation.

• Avoid wearing constricting bras and clothing so milk can flow easily. During feedings, massage or gently rub your breasts if pressure around the sore area feels good.

If you don’t feel better within twenty-four hours after starting antibiotic treatment, call your caregiver. You may need a different antibiotic.

Expressing and Storing Breast Milk

When your baby isn’t available or able to nurse, you need to express your milk to relieve fullness and maintain your milk supply. Although expressing your milk by hand or by pump may seem daunting, both become easier with practice. For either method, all you need are clean hands, clean equipment, and clean containers for storing your milk.

HAND EXPRESSION

This method is effective, inexpensive, and always available. (See page 420.) When you first learn to express by hand, you may get only drops of milk. You soon express a steady spray of milk after a little practice. Collect your milk in a measuring cup or special milk-collecting device.

WHEN PUMPING IS HELPFUL OR NECESSARY

In the following situations, using a pump to express your milk is more efficient and desirable than hand-expressing:

• You must leave your baby because of travel or work outside your home.

• Your baby is in the neonatal intensive care unit (NICU) or special care nursery and can’t breastfeed or can’t yet feed frequently or vigorously.

• You’re trying to build or rebuild your milk supply.

• Your baby can’t get enough milk by breastfeeding alone and must have supplemental breast milk.

• You’re having a medical procedure that requires you to take a medication that’s unsafe for your baby. You may need to temporarily stop breastfeeding, but you can still maintain your milk supply by pumping until breastfeeding is safe to resume. In this case, you don’t save the pumped milk for your baby to drink later.

FINDING AND USING A BREAST PUMP

A lactation consultant, La Leche League Leader, or your caregiver can help you select a pump. (You may also visit http://www.kellymom.com for a discussion on pump selection.) If your baby needs only an occasional bottle, hand expression or a manual pump is sufficient to collect the milk. If you need to pump several bottles a day or if you’re building or maintaining your milk supply, you may need an electric pump. Commercial-grade electric double breast pumps are the most efficient and effective; they’re available to rent. Or you can purchase a personal-use model, which is almost as effective. Be sure to follow the directions for use.

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When using a pump, always center your nipple in the pump cup (flange). When the nipple isn’t centered, friction on the areola causes soreness. Use only enough suction to make milk flow well. Too much suction stretches the areola and pulls it too deeply into the pump cup, possibly injuring the tissue and causing nipple soreness. Many pumps come with different-size pump cups to fit different breasts. Some have a soft silicone insert to increase comfort. If your pump’s cup seems too large or too small, check with the pump manufacturer to find the right size for you.

If you want to multitask while pumping, you can buy a device to hold an electric pump’s cups in place so you can use your hands for other tasks. To make your own “handsfree” device, buy an inexpensive sports bra and cut slits in the center of each bra cup that are wide enough to hold the pump cups snugly against your breasts.

The following suggestions may help increase milk flow when pumping:

• Find a private, warm environment that’s free of interruptions and distractions.

• Before pumping, cup your breasts and gently but firmly stroke them from your chest toward your areola. You can also jiggle or gently shake your breasts, or stroke them lightly with your fingertips to simulate the sensations of let-down.

• Develop a pumping ritual such as having a cup of tea or listening to relaxing music.

• Imagine you’re nursing your baby or look at photos of your baby and visualize your milk flowing.

STORING BREAST MILK

You can store expressed breast milk in clean glass bottles or jars, plastic bottles, or feeding bags designed for breast milk storage. Experts debate whether glass or plastic is the safest container for breast milk; see page 436 for further information.

USING STORED BREAST MILK

Use stored breast milk in the following order:

1.  Freshly expressed milk

2.  Newly refrigerated milk, then all other refrigerated milk

3.  Frozen milk (use oldest container first, to keep your entire supply as fresh as possible)

How to Store Breast Milk

The following guidelines explain where and how long to store breast milk for healthy, full-term babies. (Mothers whose babies are ill or premature may need to follow other storage guidelines.) When storing milk for longer than a day, label the container with the collection date.

• For ten hours in a room whose temperature ranges from 66°F to 72°F (19°C to 22°C)

• For eight days in a refrigerator set at 32°F to 39°F (0°C to 3.8°C)

• For three to six months in a standard freezer set to the coldest setting (Place the milk at the back, where the temperature remains coldest. Also, before freezing breast milk, leave room at the top of the container for expansion. Don’t refreeze thawed milk.)

• For six months in a deep freezer set to 0°F (-18°C) or colder. (Frozen milk is an excellent source of nutrition for up to six months.52,53)

To warm refrigerated breast milk or thaw frozen milk, never use a microwave or a stove. Using either appliance to heat the milk can destroy many important anti-infective properties and may heat the milk unevenly, increasing the risk of hot spots that can burn your baby. Instead, place the milk container in a bowl of warm water. As the water cools, replace it with more warm water. Your baby can drink breast milk that’s at room temperature or slightly warmer. When the breast milk is warmed, before giving the bottle to your baby swirl it gently to mix the fat (which rises to the top during storage) back into the milk. You can safely store thawed breast milk in the refrigerator for up to twenty-four hours, but don’t refreeze it.54

Breast milk does lose some (but not all) of its anti-infective and nutritional properties over time and with freezing and heating. Regardless, it’s still far more nutritious than formula.

Feeding Your Baby Expressed Breast Milk or Supplemental Formula

Whenever a breastfed baby can’t nurse or needs extra milk, providing expressed breast milk is best. When that’s not possible, an appropriate formula is acceptable.

How you feed your baby expressed breast milk or formula depends on many factors, including your baby’s age and maturity, how long you’re apart from her, and whether the supplementation is permanent or temporary. In complicated situations, a lactation consultant can help you figure out how best to feed your baby. The following are ways to give a supplemental feed to your baby:

Tubes

For this method, you use paper tape to attach tubes next to your nipple. Depending on the device used, you either pin the milk container (syringe, bottle, or bag) to your shirt or hang it from a cord around your neck. As your baby nurses, she draws milk from the container through the tubes. A tube device may be for temporary use, but if you persistently can’t produce enough milk during a feeding, you can use the device for as long as necessary. A lactation consultant can show you how to use it.

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Droppers, spoons, and small cups

You can use these items to feed your baby small amounts of supplemental milk. They provide a temporary solution for supplementation and prevent an early introduction to bottle nipples, which may cause nipple confusion.

Bottles

If your baby needs help feeding or gaining weight, you can use bottles to provide supplemental breast milk or formula. If you’re gone for an extended time (such as when you return to work), your baby can feed from bottles.

If possible, wait to introduce a bottle until you’re certain your baby is nursing well and gaining weight steadily (usually four weeks or so after you’ve begun breastfeeding). Begin introducing a bottle about two weeks before your baby will need to feed from it while you’re away. The first bottle-feeding may be challenging for you or your partner, friend, or child-care provider. Some babies learn quickly; others suck only once then stop. It may take a while for your baby to learn to bottle-feed or accept a bottle. See page 436 for more information on bottle-feeding.

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When Your Breastfed Baby Refuses a Bottle

If your baby is reluctant to take a bottle, consider these suggestions:

• Let your baby learn to suck from a bottle when he’s calm.

• Choose a bottle and nipple brand that seems durable and easy to clean, then stick with it until your baby becomes familiar with it.

• Introduce a bottle before expecting your baby to take his entire feeding from it. At first, offer 1/2 to 1 ounce of milk after a breastfeeding session.

• Warm the bottle and nipple with running warm water.

• Your baby may accept a bottle if you hold him as you do for breastfeeding. Or he may better accept it if you distract him by talking, singing, or doing something else you don’t do while breastfeeding.

• If your baby absolutely refuses the bottle, don’t force him to take it. Use a dropper, cup, or spoon to feed him enough milk to take the edge off his hunger, then try again later with the bottle. Until he accepts this method of feeding, engage the help of someone experienced with bottle-feeding.

• If you want to continue breastfeeding, make sure your baby has more opportunities to breastfeed than bottle-feed.

Situations That May Make

Breastfeeding Challenging

Sometimes circumstances leave breastfeeding mothers and their babies needing more support and persistence than usual to establish or continue breastfeeding. Ask your caregiver, a childbirth educator, or your baby’s caregiver to refer you to a lactation consultant who can help in challenging situations such as the following.

CESAREAN BIRTH OR DIFFICULT LABOR AND BIRTH

Recovering from a cesarean can be challenging (see Chapter 14) as can recovering from a long and difficult labor and birth. In either case, you may be exhausted and require more medical and nursing care. Repairing your incision, episiotomy, or lacerations or resolving any medical emergency (such as hemorrhaging) may delay your first breastfeeding, which in turn may delay when your milk comes in.55 If you had a cesarean, the smaller and less frequent releases of oxytocin and minimal rise in prolactin levels may also delay your milk.56

Despite the challenges, studies show that women who had cesareans or difficult labors and births—and who have a solid commitment to breastfeeding—tend to breastfeed for as long as women who had uncomplicated vaginal births.57

To help establish breastfeeding after a cesarean or difficult labor and birth, ask to see, hold, and nurse your baby as soon as possible. Breastfeeding before the epidural or spinal anesthetic wears off helps reduce any pain you may feel. Nurse your baby frequently while lying on your side and take advantage of any help offered.

After you and your baby are home, concentrate on rest, comfort, and feeding your baby. Arrange for help with household chores. You may find it most comfortable to breastfeed while lying down or sitting upright with your back supported and a pillow on your lap.

Continue to take your pain relief medication, which appears in breast milk in only trace amounts. Unrelieved pain can make breastfeeding and baby care more difficult.58

PREMATURE, ILL, OR HOSPITALIZED BABIES

If your baby is premature, ill, or hospitalized, you may feel sad and worried about her well-being. Breastfeeding lets you care for your baby in an important way by giving her the closeness and comfort she needs, and your breast milk helps bolster her immune system and protect against infections.

When compared to mothers of full-term babies, mothers of premature babies produce milk that’s higher in protein, nitrogen, sodium, calcium, fat, and calories. Because hospitalized premature babies are at risk for infection, breast milk’s protective components are especially important. Breastfed premature babies have lower rates of infection and serious bowel problems than do formula-fed premature babies.59Also, when compared to formula-fed premature babies, breastfed premature babies have higher IQ scores at age eight.60

If your baby can’t nurse or can’t yet suckle well, express your colostrum or milk with a pump. As soon as your baby can take nourishment by mouth, feed her the expressed colostrum and milk by tube or dropper until she can nurse. Spend time in the hospital nursery with your baby to expose yourself to some of the organisms that can cause infection in her. Your mature immune system can make antibodies to protect you from these organisms. The antibodies appear in your breast milk and protect your baby from infection when she consumes it. Your ability to make antibodies increases when you hold your baby skin-to-skin. (See page 293.)

To establish and maintain your milk supply and to overcome obstacles you may encounter, secure the continuing support of your partner, the nursing staff, or a lactation consultant. Other parents of premature or hospitalized infants can help immensely by giving advice on breastfeeding and on other practical matters.

NURSING WHILE PREGNANT

If you become pregnant while nursing another child, you need to decide whether to continue breastfeeding or to wean your child. Breastfeeding doesn’t harm a pregnancy; at birth, babies whose mothers nursed through a pregnancy are of similar size to babies whose mothers weaned before becoming pregnant.61

You may find that early pregnancy symptoms, especially sore nipples and fatigue, interfere with breastfeeding. In addition, as the hormones produced during pregnancy decrease the volume of your milk and cause its flavor to change, your child may become less interested in nursing. But generally, if you’re healthy and well nourished, you may have no difficulty nursing through your pregnancy.

If you choose to wean your child, see page 433.

TANDEM NURSING

A mother who breastfeeds a newborn and older child at the same time is tandem nursing. Sometimes, the older child’s desire to nurse is temporary as she adjusts to the new baby; sometimes, she just wants to nurse occasionally. In these situations, tandem nursing provides an opportunity for the mother, older child, and baby to bond together.

When you tandem nurse, feed your newborn first to satisfy his needs for colostrum and breast milk. Encourage the older child to wait until the baby has finished feeding. Once your mature milk is in and you’re breastfeeding your newborn without problems, you can nurse both children at the same time.

Tandem nursing is challenging when the older child nurses very frequently and can’t wait to feed. In this case, get support from La Leche League, a lactation consultant, or a childbirth or parent educator to help and reassure you.

BREASTFEEDING MULTIPLES

Breastfeeding multiples is more complex than breastfeeding one baby, especially if the babies were born prematurely. However, nursing twins or triplets is very possible; even exclusive breastfeeding is feasible.

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As soon as you discover you’re pregnant with multiples, begin seeking the help you’ll need after the babies are born. Contact a lactation consultant to learn about the special challenges of feeding multiples and about useful equipment that makes feeding easier (such as breastfeeding pillows). A lactation consultant also can help you arrange for support in the early days and weeks after the birth. Postpartum doulas are especially helpful to mothers of multiples (see page 27) as are support groups for parents of multiples.

In the beginning, it may be easier to feed one baby at a time. As you become comfortable with breastfeeding, nursing two babies at once (if they’re willing) saves you time.

Make sure to eat well and eat enough; your caloric needs are greater than those of mothers feeding one baby. (See page 417.)

BREASTFEEDING WHEN YOU’RE ILL OR HOSPITALIZED

Depending on your condition and the treatments you’re receiving while hospitalized, you may have several options for baby care and feeding. Speak with the hospital’s lactation consultant for guidance. If your baby can stay with you, you can breastfeed her or pump your milk and have a chance to cuddle her. Many hospitals let your partner stay in your room and care for your baby. If separated from your baby, you may be able to pump your milk so your baby can have it at home.

TAKING MEDICATIONS AND DRUGS DURING LACTATION

With few exceptions, any medication or drug you take is present to some degree in your breast milk. Some medications do affect your baby, but most don’t. For example, pain relief medications used after birth are generally safe for breastfeeding, and it’s important to take them for your comfort. Likewise, stool softeners and hemorrhoid medications don’t significantly affect breast milk.

Before taking any prescription or over-the-counter medications or any herbal remedies, always consult with your and your baby’s caregivers or a lactation consultant about the safety of taking the medication or drug while breastfeeding. You should always avoid taking street drugs (cocaine, heroin, methamphetamines, and so on), because the effects of these drugs pose serious health risks for you and your breastfeeding baby.

Health care experts consider most vaccinations safe for breastfeeding mothers. One exception, however, is the smallpox vaccination. Breastfeeding mothers should avoid this vaccination because it causes a sore to develop at the vaccination site. If a baby is exposed to the sore, it may cause sores to develop on his skin. If you want a flu shot or a vaccination against mumps, measles, and rubella (MMR), both are safe to have if breastfeeding.62

If you take oral contraceptives, avoid those containing estrogen. These birth control pills can decrease your milk supply. Progestin-only contraceptives, including the mini-pill and Depo-Provera, don’t interfere with milk production.

Smoking affects babies in two ways: by ingesting breast milk containing nicotine and other chemicals in tobacco and by breathing in smoke. Even though smoking can create problems for a baby (such as increased fussiness63), a mother who smokes should still breastfeed her baby. Breast milk produced by a smoker better protects a baby’s health than formula does. Formula-fed babies of smoking mothers are seven times more likely to develop respiratory illnesses than are breastfed babies of smokers.64

If you smoke, try to quit or at least cut down the number of cigarettes you smoke each day. When you do smoke, avoid doing so around your baby. Secondhand smoke increases a baby’s risk of sudden infant death syndrome (SIDS) and incidences of respiratory infections and ear infections.

Questions about Medications and Breastfeeding

Before taking any medication or herbal remedy, ask your caregiver or lactation consultant the following questions:

• Do I absolutely need this medication now? Can I delay taking it until my baby is more mature and can better handle its effects?

• Is there a safer alternative to the medication?

• Can I take the medication topically (rubbed on the skin) instead of orally? (When compared to oral medications, topical medications usually pass into your bloodstream and breast milk in lower levels.)

• Can we schedule the timing of the medication or the feedings so the smallest amount of the drug is in my breast milk when feeding? (Time-release medications and some drugs take a long time to leave the body.)

• When I take medications that are unsafe for breastfeeding, should I temporarily stop nursing? (If the answer is yes, you can pump and discard your milk until the treatment is complete and the medication is out of your system.)

• What symptoms and possible side effects from medication should I watch for in my baby?

• Do you have access to the most accurate information about medication use during breastfeeding? (For example, Medications and Mothers’ Milk by Thomas W. Hale is a regularly revised book on the subject that’s well respected in the medical community.)

WORKING OUTSIDE THE HOME

When you work outside your home, breastfeeding your baby is possible with planning and support. The extra effort to nurse your baby during the workday, or to express and store your milk, pays off in the following ways:

• By keeping up your milk supply

• By providing your baby with nourishment that can protect him from acquiring infections while in day care

• By maintaining the closeness with your baby that comes with breastfeeding

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In general, a lengthy maternity leave and a flexible job make it easier to combine breastfeeding and work. Continuing breastfeeding while working is less difficult when a maternity leave lasts at least until the baby nurses less frequently and on a more predictable schedule (for example, when he starts eating table foods).

Most industrialized countries provide mothers with maternity leaves that last a year or more, allowing time for babies to naturally reduce their need to nurse and better adjust to long breaks between feedings. In the United States, however, maternity leaves are often very short (usually no longer than twelve weeks).

Political action groups such as MomsRising (http://www.momsrising.com) are working to increase the length of parental leave, but until that change occurs, breastfeeding parents in the United States must make the most of whatever leave they’re granted and plan how they’ll continuing breastfeeding when the leave is over. Before returning to work, research your workplace’s policy and attitudes (as well as your legal rights) about breastfeeding.

When planning a return to the workplace, you have several options for continuing breastfeeding. For example, consider switching to part-time employment or discuss with your employer the possibility of telecommuting part- or full-time. Either option will make you available to nurse your baby regularly during the workday. To further persuade your employer of the importance of breastfeeding, you may also want to let him or her know that women who breastfeed take less time off, because their breastfed children get sick less often.

If your workplace is close to where your baby is during the workday, arrange to work longer hours so you can take one to two long feeding breaks during the day. Either your baby can come to you (if your workplace supports that option) or you can go to your baby. If your baby is in day care, choose one that supports breastfeeding and won’t mind if you stop by to nurse your baby.

If feeding your baby during the workday isn’t an option, speak with your employer to arrange for time and privacy to express or pump milk at work. Mother-friendly workplaces often provide a room other than a restroom for working mothers to pump. Follow the guidelines on page 426 to store your milk. Mothers who can’t pump at work can still breastfeed by feeding frequently when at home. Many babies of these mothers go on a “reverse feeding” schedule; that is, they nurse infrequently during the day and feed mostly in the evenings and at night.

Some working mothers decide to breastfeed while at home and supplement with formula while away. As long as you continue to nurse frequently when you’re with your baby, you should produce enough milk. If your milk supply begins to dwindle, increase the number of feedings to stimulate your milk production.

For more information on breastfeeding while working, contact La Leche League or check if a local hospital, clinic, or health department offers a class on breastfeeding and returning to work. Talk with women who have returned to work and breastfed successfully.

RELACTATION

If breastfeeding has been interrupted long enough to stop your milk production, it’s possible to restart it—but it requires persistence, commitment, and a baby interested in nursing.

Frequent, around-the-clock nursing is the most effective method to reestablish lactation. You may use a tube-feeding device to encourage your baby to suckle at an empty or near-empty breast while receiving supplemental formula. (See page 426.) The suckling stimulates milk production while the device provides your baby with nutrition. Using an electric breast pump after a feeding may also increase your milk supply, as may taking herbal medications and prescribed medications (see page 416). If you decide to reestablish breastfeeding, contact a lactation consultant for support and advice.

Mothers of adopted babies can use these same methods to try to produce milk, even if they’ve never been pregnant or nursed a baby. Although these mothers usually don’t produce a full supply, they may produce some milk. Feeding a baby even a small amount of breast milk reduces her likelihood of having problems that are common with formula-fed babies (such as constipation). If a mother can’t produce milk to feed her adopted baby, she can still experience breastfeeding to a large degree by using a tube-feeding device to feed her formula.

BREASTFEEDING AND FERTILITY

For as long as you exclusively breastfeed your baby, you greatly reduce your chance of becoming pregnant. You have less than a 2 percent chance of becoming pregnant if:

• Your baby is less than six months old.

• You don’t menstruate until after fifty-six days postpartum.

• You’re nursing frequently (at least every four hours during the day and every six hours at night).

• You rarely supplement your baby’s feedings and give him tastes of foods or fluids only occasionally.65

After your baby has begun eating table foods, you can extend some of breastfeeding’s contraceptive benefits by nursing before offering table foods and by continuing to breastfeed throughout the day and night.

After giving birth, you may ovulate before you have your first menstrual period. If preventing pregnancy is essential or desirable, talk to your caregiver about contraception. Barrier methods (condoms and diaphragms), intrauterine devices (IUDs), and progestin-only pills and injections (mini-pill and Depo-Provera) don’t interfere with breastfeeding. Birth control pills containing estrogen, however, can reduce your milk supply.66

Identifying your body’s fertility signs is trickier when you’re nursing because of the fluctuating hormone levels required for breastfeeding, but it can be done. If you’re interested in learning about fertility awareness techniques, the excellent book Taking Charge of Your Fertility: The Definitive Guide to Natural Birth Control, Pregnancy Achievement, and Reproductive Health by Toni Weschler may give you the information you need.67

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WEANING

You may have heard that it’s okay to wean your baby when she’s six months old (or has teeth) because breast milk is most beneficial up to that time—but this information is incorrect. Breast milk benefits your baby for as long as you decide to breastfeed. In fact, the American Academy of Pediatrics (AAP) recommends breastfeeding babies for the first year or longer.

Making the decision to wean is complex; don’t make your decision based on other’s opinions or suggestions. You may decide to wean because you want to become pregnant and can’t while breastfeeding. Or you may decide that demands at work make it difficult to continue nursing. Sometimes, the decision to wean isn’t the mother’s: Perhaps the child is no longer interested in nursing. Or, in very sad cases, the child has died.

Fact or Fiction?

You should continue to breastfeed your baby after he has begun to eat other foods.

Fact. The American Academy of Pediatrics recommends that mothers exclusively breastfeed their babies for the first six months. When their babies are around six months old, parents can gradually begin introducing table foods, including foods rich in iron. However, breast milk or formula is still the most important food in a baby’s diet for the rest of the first year. After the first year, mothers and babies can continue breastfeeding for as long as they desire. If babies are weaned before their first birthdays, they should consume an iron-fortified cow milk formula.

When you decide to wean your child, here are some practical tips to make the transition easier:

• Wean slowly. This way, if you change your mind and want to resume breastfeeding, you can rebuild your milk supply.

• First cut out the feeding you and your baby enjoy least. After your baby and you have adjusted to that change, continue to slowly cut out feedings one at a time, leaving the best-loved feeding (such as the first feeding of the day or the one that’s part of the bedtime ritual) for last.

• When preparing bottles, gradually replace breast milk with formula or whole cow or goat milk, depending on your baby’s age.

• Use the comfort measures discussed on pages 419 to treat swollen breasts.

• If you’re thinking of weaning your child in the winter, wait until the spring to give her the best chance of staying healthy during the cold and flu season.

• Think of the ways you cuddled with your baby as you breastfed her. For example, you may have read a book together in a rocking chair, bathed together, or napped together. You can still do these special things while weaning your baby.

• Honor the time you nursed. Write your baby a letter about what nursing her meant to you.

• As you wean, your hormone levels change, bringing about the return of your menstrual cycle. Expect your emotions to fluctuate as your body adjusts.

• After weaning, some milk remains in your breasts. It gradually disappears over the following weeks to months.

When You Need to Wean

Sometimes, mothers must wean after the occurrence or development of an unexpected event, such as the death of a baby or a serious medical condition in the mother. In these cases, there is sadness, grief, and uncertainty.

If a mother must wean because of a medical reason or to begin infertility treatments, it’s possible to wean gradually over several days. If a baby has died, a mother doesn’t need to immediately suppress milk production. After a baby’s death, a mother may experience a “second grieving” for the baby who’s no longer there to nurse. Some women find comfort in donating their expressed milk to a milk bank in remembrance of their babies. (For more on infant death, see page 303.)

To comfortably suppress milk production, wear a snug-fitting supportive bra (such as a sports bra) to provide comfort as your breasts swell. Apply ice packs to your breasts over your bra or light clothing and take ibuprofen to reduce inflammation. Sore breasts may last for a day or two, but you may leak milk for a week or longer. For more on lactation suppression, see page 334.

Formula Feeding and Bottle-feeding

When breastfeeding isn’t possible or desired, parents typically bottle-feed their baby formula (when breast milk isn’t available) or expressed breast milk.

TYPES OF FORMULAS AND FORMULA PREPARATION

For families who feed their babies formula, the American Academy of Pediatrics (AAP) recommends using formulas that are iron-fortified and commercially prepared to feed babies younger than one year.68Evaporated milk mixtures don’t suit a baby’s nutritional needs. Whole, 2 percent, 1 percent, or fat-free cow milk or goat milk lack many important and necessary nutrients, and are difficult to digest for babies younger than one year. Because commercially prepared formulas are fortified with vitamins and minerals, babies who consume them don’t require a vitamin and mineral supplement.

Your baby’s caregiver can give you guidelines on how much to feed your baby. A rule of thumb is that in a 24-hour period, a baby needs 2 to 21⁄2 ounces for every pound he weighs.

TYPES OF FORMULAS

Most infant formulas are made of cow milk or soybeans, and many are fortified with iron to reduce a baby’s risk of becoming anemic (having low iron). Contrary to myth, consuming iron-fortified formula doesn’t increase the incidence of colic, constipation, diarrhea, fussiness, or vomiting. In fact, research suggests that babies who consumed low-iron formula have lower cognitive test scores at age five than do their peers who didn’t consume low-iron formula.69 Except when a baby has a rare medical condition, the best formula for a baby’s overall health is one fortified with iron and preferably made of cow milk.

Some parents switch brands of formula after noticing one brand seems to make their baby gassy or fussy. Switching formulas, however, does not decrease gas or reduce fussiness. All babies—breastfed and formula-fed—are gassy and fussy at times, and parents should stick with the brand of formula that their baby tolerates.

Sometimes, formulas truly don’t agree with babies. For example, if your baby seems allergic to iron-fortified, cow milk formula, his caregiver may suggest hypoallergenic formulas, which are more expensive than other formulas.

If your baby can’t digest lactose (galactosemia) or if your family eats a vegan diet (doesn’t include animal protein), your caregiver may recommend an iron-fortified soymilk formula. Because up to 25 percent of babies with a milk allergy are also allergic to soy,70 health care providers recommend using soy formulas in only these cases.

PREPARING FORMULA

Formulas are available in ready-to-feed bottles or cans, canned liquid concentrates, and powdered forms. When prepared as directed, all three forms have equal nutritive value. Powdered formula is least expensive and ready-to-feed formula is most expensive, with concentrated formula slightly less so.

When preparing formula, carefully follow the package directions. Make sure your hands and all equipment are clean. Always use the correct amount of water to mix powdered or concentrated formula. If you use too little water, you can cause diarrhea, dehydration, and other problems for your baby. If you use too much water, you dilute the formula and your baby doesn’t receive enough calories and nutrients to thrive. Formula-fed babies don’t need extra water until they begin eating table foods.

If your water supply is fluoridated, mix formula with distilled, purified water that’s free of minerals and ions, or water that’s been filtered by reverse osmosis. The American Academy of Pediatric Dentistry reports that using fluoridated water to prepare formula can permanently discolor teeth when babies consume fluoride in greater than optimal amounts.71

BOTTLES AND NIPPLES

Although bottles come in many shapes and styles, most are made of either glass or plastic. Because plastic bottles are lightweight and don’t crack or break easily, they seem the more practical choice. But the current debate on the toxicity of clear plastic bottles made of polycarbonate (which contains the chemical bisphenol A, or BPA) may persuade some parents to choose glass bottles or BPA-free plastic bottles.

Experts are split on the dangers of BPA. On one side, the National Institutes of Health reports that BPA may affect the neurology and behavior of babies and children, and the Environment California Research & Policy Center recommends that parents avoid giving their children plastic bottles or cups made of polycarbonate.72 On the other side, the U.S. Food and Drug Administration (FDA) finds the use of BPA in plastic bottles and cups of no concern.

If you want to limit your baby’s exposure to BPA, consider using glass bottles, which are stain-proof and easy to clean but are heavy and can break. If plastic bottles are more practical for you, avoid using those that have the recycling symbol 7; they contain BPA. Instead, choose bottles with the recycling symbols 1, 2, or 5; they’re made of polyethylene or polypropylene.

Some parents use a feeding-bag system to avoid using bottles, even though it’s harder to prepare formula this way. Some feeding units consist of a disposable plastic bag (for the formula) inside a plastic container, and it’s not as easy to mix formula in a bag as it is in a bottle. If you choose this system, check the manufacturer’s information to determine if the bag and container are BPA free. For other feeding supplies that don’t contain BPA, visit http://www.thesoftlanding.com.

Like bottles, nipples also come in various shapes and sizes. Select one your baby likes and then stay with that type of nipple. Before feeding your baby a bottle, check that the breast milk or formula drips adequately from the nipple. If it flows in a stream, the nipple hole is too big and your baby may consume too much too fast and she may spit up. If the milk drips very slowly or not at all, your baby may tire of sucking and not consume enough (or any) milk. If the nipple hole is too large, discard the nipple. If it’s too small, remove any dried breast milk or formula that may be clogging the hole or enlarge the hole with a clean needle, then check the drip again.

If your water supply is safe for drinking, you don’t need to sterilize bottles and nipples. You can wash bottles by hand or in the dishwasher. Clean nipples with a nipple brush and hot soapy water; rinse them with hot water and dry.

Heat bottles in warm water; don’t use a microwave or stove. These appliances may produce hot spots that can burn your baby. Plus, if using plastic bottles, the high heating is more likely to release chemicals into the breast milk or formula.

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TIPS FOR BOTTLE-FEEDING

Giving your baby a bottle can be an enjoyable experience. Cuddle your baby during feedings or even hold him skin-to-skin to give him the closeness he needs, promote bonding, and provide you with wonderful memories.

You can make your baby’s feedings consistently successful and happy by doing the following:

• Hold your baby so he’s semi-reclined. This position is more comfortable for him than lying on his back and prevents him from swallowing too much air.

• To promote normal development of your baby’s eye muscles and symmetrical development of his neck muscles, hold him sometimes in your right arm and sometimes in your left.

• Burp your baby about halfway through a feeding. Babies that gulp air need to burp more often. As he grows, he’ll begin to burp on his own and won’t need your help. See pages 410–411 for tips on burping your baby and preventing spitting up.

• Trust that your baby knows how much he needs to eat. For the first few days after the birth, full-term babies feed eight to twelve times in twenty-four hours. As they grow, they consume more at each feeding and eat less often. Your baby might not want to consume the same amount at each feeding. If he doesn’t finish a bottle, don’t coax him to do so if he seems satisfied. When your baby rapidly and consistently finishes a bottle at each feeding, add more breast milk or formula (typically 1 ounce) to the bottle for the next feeding. Your baby’s caregiver can give you guidelines on how much to feed your baby at each feeding.

• Offering your baby warmed (but not hot) breast milk or formula can make the feeding more comfortable. As he grows, he may begin to prefer a bottle that’s cool or at room temperature.

• Never prop a bottle to feed your baby. Interacting with you and others during feedings helps him thrive emotionally and develop trust.

• Never mix cooked or raw honey into your baby’s bottle (or dip his pacifiers in honey). Infant botulism can occur in babies younger than one year.

Key Points to Remember

• Feeding your baby has far greater significance than simply providing for her physical growth. Consistently responding to her feeding cues develops her sense of trust, security, and well-being. Cuddling your baby during feedings, while smiling and talking to her, promotes emotional development and stimulates her senses.

• Feeding your baby also provides many opportunities for her to coo, grin, pat, and otherwise express affection toward you, fostering bonding and strengthening family ties.

• Under most circumstances, breastfeeding is the best way to feed babies. With more than two hundred nutrients, breast milk is easily digestible, promotes your baby’s overall health, and helps prevent some illnesses and diseases. Breastfeeding also offers unique health benefits to you.

• Breastfeed your baby whenever she shows feeding cues (typically eight to twelve times a day for a newborn). Let her feed for as long as she wants on the first breast (ten to thirty minutes), then offer the second breast. Count the number of wet and poopy diapers and monitor her weight gain to know she’s getting plenty of milk.

• Many breastfeeding challenges have several effective remedies. Lactation consultants, physicians specializing in breastfeeding medicine, and your caregiver can help you remedy most breastfeeding problems.

• In most cases when using formula, you should feed your baby an iron-fortified cow milk formula.

• When bottle-feeding your baby, feed her whenever she shows feeding cues and always hold her to provide the emotional interaction and love she needs.