Sandra Londino, MS, CNM, LM 235 Elm Street Ithaca, NY 14850 ph: 607.342.1633 | fax: 866.977.4171

birthrootithaca@gmail.com

Breastfeeding Basics Congratulations on choosing to breastfeed! Your milk provides excellent nutrition, and gives your baby immunity and protection from illnesses that no other food can. Although breastfeeding is a “natural” process, breastfeeding requires some skills that both parent and baby need to learn and perfect. With patience, perseverance, and the correct information you will be able to establish a successful breastfeeding relationship with your baby. SKIN-TO-SKIN CONTACT Skin-to-skin isn’t just important right after the birth. It’s also beneficial for encouraging and supporting breastfeeding in the first few weeks. Many new parents (or grandparents!) are excited to get all those cute baby clothes onto their babies right away, but it’s a good idea to wait a while and keep your baby skin-to-skin with you. Newborns like to smell and touch your skin, and this helps them to relax and gives them important cues that the breast is near and it’s time to nurse. COLOSTRUM Colostrum is your baby’s first food. It is all your baby needs for the first few days until your milk comes in. This special milk is yellow to orange in color and thick and sticky. Colostrum is extremely easy to digest, and is therefore the perfect first food for your baby. It is low in volume (measurable in teaspoons rather than ounces), but high in concentrated nutrition for your baby. Colostrum has a laxative effect on the baby, helping them pass the meconium, which aids in the excretion of excess bilirubin and helps prevent jaundice. You should nurse your baby at least 10-12 times each 24 hours, and more than that is even better. Frequent nursing stimulates production of milk and allows your baby to get all the benefits of the colostrum. Colostrum is amazing! It is literally alive with living cells, antibodies, and immune factors that protect your baby against infection. It is rich in protein, carbohydrates, minerals, and vitamins in just the right amounts to provide perfect nutrition for your baby. Colostrum plays an important role in the maturation of the baby’s digestive tract. At birth, a newborn’s intestines are very permeable, meaning they allow substances to pass in and out. In general, this is not a good thing as undigested nutrients in the bloodstream can lead to allergies and auto-immune conditions. Colostrum seals the intestinal tract with a barrier that prevents foreign substances from entering the bloodstream. Many new parents worry that their babies won’t get enough nutrition during the first few days while the baby is only receiving colostrum. The short answer is that colostrum is the only food healthy, full-term babies need. As you can see here, the capacity of a newborn’s stomach on the first day of life is about the size of a cherry. By about 2-3 days of life, the baby’s stomach capacity is about the size of a walnut or 4-6 teaspoons.

As you can see, small frequent feedings will be important. This is why your newborn will want to nurse seemingly round the clock. It’s not because they aren’t getting enough food! It’s because the colostrum is very easily digested and they can only hold a very small amount at each feeding.

Newborns do lose weight in the first week after birth. This is due to normal fluid loss after delivery. Don’t worry about it! Most babies lose around 5-7% of their original birth weight in the first few days, and up to 10% weight loss is considered normal. Most newborns will be back up to their original birth weight by 10-14 days after birth. If for some reason, the baby is not nursing well in the first few days, you can hand express colostrum to feed to your baby with a syringe or a spoon. Don’t try to pump colostrum with a breast pump! You will become discouraged and frustrated. Remember: colostrum is measured in teaspoons, not ounces! Hand expressing is the best way to get colostrum and you will only end up with a few drops. This is normal! This is how much you should expect. A lactation consultant can be very helpful in dispelling myths and unnecessary worry about what’s happening in the first few days. They can help you with good positioning and latch, instruct you how to hand express and feed colostrum to your baby if necessary, and help you determine when formula may be truly beneficial in certain rare cases. WHEN DOES THE MILK COME IN? True milk comes in somewhere between 3-7 days postpartum. This is not an abrupt shift; the colostrum gradually changes to mature milk during the first two weeks after birth. During this time, the concentration of antibodies in your milk decreases, but the milk volume greatly increases. The amazing disease-fighting properties of colostrum don’t go away when the milk comes in, however. There are still antibodies in milk that will be present as long as you are breastfeeding, and your baby will receive protection from many different viruses and bacteria. How will you know that your milk has come in? Your breasts will feel different and your baby will act differently while nursing. There can sometimes be a temporary rise in your temperature when your milk first comes in; you may notice that you feel feverish and may think you’re getting sick. This usually goes away after 12-24 hours. Your breasts will feel fuller and firmer when the milk comes in. When your baby nurses, you will notice the baby gulping and swallowing much more because the volume of fluid increases with mature milk. ENGORGEMENT You may initially feel significant engorgement and fullness when your milk comes in. The following suggestions may help to relieve sore and swollen breasts in the early weeks of breastfeeding:

ü Prevention is better than treatment! Nurse as often as your baby wants. Most severe engorgement can be prevented by early and frequent breastfeeding.

ü Warm compresses, showers, or baths will stimulate the flow of milk and relieve pressure. It’s best to use warm treatments before breastfeeding.

ü Cold compresses, frozen vegetable bags (wrapped in a towel), frozen washcloths, ice packs, or cold green cabbage leaves placed on your breasts may provide relief. Roll or crush the cabbage leaves first before applying. Use cold treatments after breastfeeding.

ü Massage your breasts and/or express milk by hand to relieve engorgement. This is easily done by standing in a warm shower with your breasts in the water stream. The warmth will stimulate milk flow.

MILK LET-DOWN When the baby sucks, the action stimulates your brain to release the hormone oxytocin into your bloodstream. Oxytocin flows into the blood vessels in your breasts and causes cells around the milk glands to contract. This has the effect of squeezing milk out through the tiny holes in your nipples. This whole process, from the baby first starting to suck, until milk actually comes out, can take up to a minute or more. When the milk first starts to come out it is called a “let-down,” named because the glands in the breasts are letting the milk come down into and out of the nipples. The let-down often feels like a stinging, buzzing, prickling feeling in both breasts and nipples, not just the one the baby is sucking on. This will immediately be followed by your baby gulping and swallowing. Many people experience nipple soreness before, during, and just after the let-down, that disappears after the first 30-60 seconds of the baby actually drinking the milk. This is normal! Please see below for more information about nipple soreness. During the first few months of breastfeeding, you will get a let-down on both sides even though your baby is only nursing on one side. This is normal, and will resolve after several months as your brain learns to coordinate the let-down process and only the breast that is being stimulated will produce milk. The best way to deal with leaking from the other side is to hold a towel or cloth underneath the other breast and just let the milk drip out. If you’re out in public, you can wear nursing pads to absorb the milk. To avoid irritated skin that might lead to sore nipples, don’t let nursing pads wet with milk sit against your skin. Change them whenever they are wet. STOPPING THE FLOW The milk-ejection reflex or let-down can also happen spontaneously when you just think about feeding your baby or when you hear your baby crying. If you can’t immediately go to your baby or you’re dripping from the other side as the baby nurses, you can stop the flow by taking the palm of your hand and pressing firmly against your breast for around 30 seconds.

LATCH AND POSITIONING There are many different ways you can hold your baby while nursing. Experiment with all of them to find what is most comfortable for you. Whatever feels best for you is fine, use what works! Just remember to make sure the baby has a good latch. This means that the baby takes a good mouthful of breast tissue, not just the nipple. A good latch is important for the following reasons:

ü It ensures your breast is properly stimulated by the baby’s mouth so that milk production and supply are adequate. If milk production and supply are adequate, your baby will get enough milk to satisfy their needs for growth and development.

ü It prevents sore, cracked, or painful nipples. With a good latch, your nipple is far back in the baby’s mouth against their soft palate. If only your nipple, and not the rest of the areola, is in their mouth, the hard palate of the baby’s mouth will rub against your nipple and cause pain.

You can tell that your baby has a good latch by noticing the following:

ü 30-60 seconds after the baby starts sucking, you should see the baby gulping and swallowing. This means your milk has let-down due to adequate stimulation of the breast. As your baby is swallowing, you should see their ears move up and down. You should hear no sounds other than sucking and swallowing. If you hear clicking noises, it’s probably not a good latch.

ü The baby’s lips should be flanged outward, not turned in. You should be able to see the pink of the baby’s lips. The baby’s tongue should be in between your breast and their lower gums. More of the areola should show above the baby’s upper lip than below the baby’s lower lip.

ü Your nipple should come out of the baby’s mouth in the same shape as before the feeding began. If your nipple is peaked, wedge-shaped, or has a white crease across the tip then the latch is not good.

ü There may be some tenderness as the baby starts sucking and brings your nipple past their hard palate. As the nipple comes to rest in the back of the baby’s mouth against their soft palate and the milk stars flowing, you will notice a lessening of the tenderness. If you continue to experience pain after the first 30-60 seconds of suckling, it’s probably a poor latch.

If it seems like you don’t have a good latch, don’t just pull the baby off. This will cause soreness and damage to your nipple. Instead, insert a finger into the corner of your baby’s mouth, break the suction, and then gently remove your nipple from the baby’s mouth. You can then readjust your positioning and try again. Eventually, you will know that your baby is latched and sucking efficiently by the way it feels. This image shows a good latch and a poor latch. Notice the wide open mouth and flanged outward lips in image A, as well as the nipple pulled all the way back to the soft palate in image B. Image C shows the baby just sucking on the nipple with the lips turned inward, and image D shows the nipple rubbing against the hard palate of the baby’s mouth.

LAID-BACK BREASTFEEDING Laid-back breastfeeding, also called biological nurturing, makes it is easier for you and your baby to follow your own instincts and cues. All you have to do is lay back and let you and your baby work together as a team. With your help, the baby will wiggle and move towards your nipple on their own. When you lay back, gravity takes over and your baby can take the breast easier and deeper, which helps reduce the risk of latching problems. The baby is close to you (skin-to-skin), their body is fully supported, and they can swallow as much as they want when the milk starts flowing. It is also much easier on you when you can lie back in a comfortable position and your arms, shoulders, and neck are well supported. You can help the baby to the breast much easier when both hands are free to do so. Here’s how you do it: Find a bed or couch where you can lean back and feel well supported. Do not lay flat, just be comfortably leaning back so that when you put your baby on your chest, gravity will keep your baby in position with their body molded to yours. Position pillows around you so that your head, neck, shoulders, and arms are well supported. Let your baby’s whole front touch your whole front. Since you’re leaning back, you don’t have a lap and your baby can rest on you in any position you like. Just make sure their whole front is against you. Let your baby’s cheek rest somewhere near your bare breast. Help your baby find the breast, or let the baby follow their own cues. Hold your breast or not, as you like. Relax and slow everything down, keep breathing slowly and deeply. Touch, talk, and look at your baby. You are a team, make sure you are connected with each other.

OTHER BREASTFEEDING POSITIONS There are lots of other positions that you can try. Experiment with what works best for you and your baby. The best time to experiment with new nursing positions is when your baby is calm, rested, and not terribly hungry. Try nursing first for a while in a position you know your baby likes and after 10 minutes or so, when your baby isn’t so hungry, try experimenting with something new. The diagrams on the next page are described starting on the top left and going clockwise around to the bottom left. Cradle Hold (top left) This is very common and many people find it comfortable. If your baby’s head wobbles a bit while resting on your forearm, use your other hand to steady their head. Side Lying (top middle) Although it is sometimes hard to figure out how to breastfeed while lying down, once you and your baby learn to do it, nighttime breastfeeding will be much easier because you will be able to rest, and even sleep, while continuing to breastfeed. This position is also helpful if you had a cesarean birth or are otherwise uncomfortable sitting up. Football or Clutch Hold (top right) This position allows for increased head support. People who had a cesarean birth find this position helpful, as the baby does not press on the incision. Position the baby far enough back so that their head can extend back and there is room between their chin and chest. Side Lying Alternatives The bottom two images show variations on side lying. The bottom right is how you can lean over and offer the top breast with the baby lying next to you. This is useful because then you don’t have to roll over and readjust both you and the baby when they want the other breast. You can just stay in the same position and keep breastfeeding. The bottom left shows the baby upside down in relation to the parent. This may help with someone has sore nipples and needs the baby to put pressure on different parts of the breast for relief.

NIPPLE SORENESS Mild, temporary nipple soreness is usually inevitable for most people who breastfeed. More severe pain that lasts throughout feedings is usually caused by a poor latch. Keep the following points in mind while you are learning how to breastfeed during the first few weeks:

ü Most nipple soreness is temporary and occurs during the first week after birth. Usually nipples feel the most sore between days 3-6 and start to feel better after that.

ü The discomfort usually occurs as the baby latches on to the breast and draws the nipple deep into their mouth. Until the milk lets down, the baby will be sucking strongly and this is when you may feel the most soreness and discomfort. Once the milk lets down after about 30-60 seconds, the soreness is relieved for the rest of the feeding.

ü Do not attempt to limit frequency of breastfeeding to avoid further soreness; this only delays the soreness and prevents the baby from receiving enough milk. Also, the breasts will not be emptied often enough, they will become engorged, and it will become difficult for the baby to latch on to the nipple.

ü Allow your nipples to air dry between feedings. If you immediately place a bra or breast pad against your breast after a feeding, it will become moist with milk and your nipple and breast will stay wet. This can cause chafing and chapping of the skin, which will contribute to soreness and discomfort. Allow your breasts to be exposed to air between feedings and any time that they become wet with milk.

ü Please call me if you experience any of the following: o Sudden, stabbing pain (this might be related to a thrush infection or other complications) o Pink, flaky skin and itchy nipples (also symptoms of thrush) o Pain that becomes so severe that you feel like giving up on breastfeeding o Cracked, bleeding, or broken skin

FEED ON DEMAND Breastfeed your baby, wherever and whenever they want. Any time your newborn fusses, offer the breast. If that is not what they want, they will let you know. Breastfeeding is not just about milk, babies like to suck for comfort, security, physical connection, and bonding. If you have just finished a nursing session, and 10 minutes later your baby is rooting against your shoulder, don’t think “You can’t be hungry again. You just ate!” Many times, the baby just wants the comfort of being skin-to-skin against your breast, sucking, and being held closely. Don’t watch the clock, watch your baby. Offer the breast at the first sign of wanting to nurse. Watch your baby for the following cues, and nurse at the earliest sign, when your baby is still calm and alert. Don’t wait until your baby is crying to offer the breast. It is hard to feed a baby that is crying frantically! Early signs of hunger: ü Wiggling, moving arms or legs ü Rooting ü Sucking on hand or fingers

Middle signs of hunger: ü Fussy, squeaking noises ü Restless ü Crying intermittently

Late signs of hunger: ü Full cry, screaming ü Skin turns red from crying and

frustration

Remember that babies need to breastfeed frequently, at least 10-12 times in 24 hours. Many newborns want to breastfeed several times an hour, even during the night. After the first couple of weeks, your baby’s stomach is about the size of their closed fist, so they cannot take much in their stomach at a time. Breastmilk is also digested and metabolized quickly, so breastfed babies feel hungry again sooner than bottlefed babies. Keep your baby close by you at all times during the first several months, sleep with them close by, and nurse as much as they want, whenever they want, for as long as they want. If this sounds overwhelming, don’t despair! It won’t last forever. A firm establishment of milk supply is based on early and frequent breastfeeding because the breasts make more milk in response to more suckling. It’s a supply and demand system: the more your baby breastfeeds, the more milk you make. Allow your baby to establish your milk supply, and when they are a few months older, you will be able to do more things to provide comfort. VARIATIONS IN STYLE Each baby’s feeding pattern is different. Let your baby determine the length of each feeding. Some babies like to feed for a short time on one side only, some like to take both breasts during each feeding, some like to suck, doze, suck, doze, and then suck some more, still others like to nurse on one side, switch to the other, and then go back to the first side. You will figure out pretty soon what your baby likes and when they like it. It is not necessary or helpful to set a rigid feeding schedule of how long to nurse at each session, how long to nurse on each side, or how long to go between feedings. If the baby is positioned and latched on well, there is no advantage to watching the clock. Assuming the baby is sucking actively, watch the baby for cues that they have finished the first breast before offering the other. Not every baby will take the other breast at every feeding, that is ok. Just let your baby tell you when they are done feeding. When the baby has finished nursing, they will come off spontaneously or fall asleep. Remember also that when babies go through growth spurts they breastfeed more frequently to keep up with increased metabolism. A baby who previously liked to nurse for 10 minutes on each side with 1-2 hours in between feedings might start nursing for 20 minutes on each side every hour. This does not mean you are not making enough milk! Let the baby breastfeed according to their hunger and desire to suck, and your body will compensate by making more milk as the baby breastfeeds more frequently. YOUR BABY IS GETTING ENOUGH MILK! It is extremely rare for a breastfeeding parent to ”not have enough milk” to satisfy their baby, especially in the U.S. where most of us are reasonably well-nourished. Remember the following guidelines if you’re concerned about your baby’s intake of milk:

ü Babies that gulp and swallow after the first 30-60 seconds of sucking are getting milk during the feeding. ü Babies that nurse at least eight times in 24 hours are getting enough milk. ü Babies that have at least 6-8 wet diapers in 24 hours are getting enough milk. Don’t expect this to happen in the

first few days; usually there will only be 1-2 diapers per day in the first few days until your milk comes in. GENERAL BREASTFEEDING SUGGESTIONS

ü Avoid the use of artificial nipples, pacifiers, teats, formula supplements, water, or glucose water during the first six weeks. Your baby does not need them, and any time spent sucking on pacifiers reduces the amount of time they could be nursing. Supplementing your baby’s diet with formula or water is unnecessary and will interfere with establishment of a good milk supply.

ü You will always produce the right amount of milk for your baby if you allow the baby to nurse as often as they want and continue to take good care of yourself. Eat nutritious foods, drink plenty of liquids, and rest as much as you can. Remember that the more your baby sucks, the more milk you make. As your baby grows, so will the amount of milk you make.

ü Sleep with or near your baby and nurse throughout the night during the first few months. Prolactin levels are highest during the night, so your baby will want to nurse frequently in between sleeping at night. The easiest way to get more sleep yourself is to sleep with or near your baby.

ü Go to La Leche League meetings if you can. Being with other breastfeeding parents reminds you that you are not alone and you will often hear about great tips and tricks as you’re sitting around nursing together.

ü In the first few weeks, adjust your schedule to the baby’s and not the other way around. Breastfeeding will be much simpler and more rewarding if you watch your baby, rather than the clock.

ü Set up a comfortable nursing space at home. This could be a rocking chair in a corner of your bedroom, or a big comfortable chair in your living room. Make sure you have something to drink nearby before you start a feeding – breastfeeding parents get thirsty!

DON’T GIVE UP! One last thing about breastfeeding: Don’t give up!!!!!! Nursing doesn’t come completely naturally and effortlessly to most people. There is a period of about 4-6 weeks when nursing can be very uncomfortable, difficult, and challenging. Stick with it! It will soon be effortless. Many parents and babies require several weeks to learn how to breastfeed successfully. If you need extra help, call me, attend La Leche League meetings, talk to someone who has already breastfed, or contact a lactation consultant.