Breastfeeding - Starting Out Right

Breastfeeding is the natural and normal way of feeding infants and young children, and human milk is the milk made specifically for human infants. Starting out right helps to ensure breastfeeding is a pleasant experience for both you and your baby. Breastfeeding should be easy and trouble free for most mothers.

The vast majority of mothers are perfectly capable of breastfeeding their babies exclusively for about six months. In fact, most mothers should be able to produce more than enough milk. Unfortunately, outdated hospital policies and routines based on bottle feeding still predominate in too many health care institutions and make breastfeeding difficult, even impossible, for too many mothers and babies. Too frequently also, these mothers blame themselves. For breastfeeding to be well and properly established, getting off to the best start from the first days can make all the difference in the world. Of course, even with a terrible start, many mothers and babies manage. And yes, many mothers just put the baby to the breast and it works just fine.

The basis of breastfeeding is getting the baby to latch on well. A baby who latches on well gets milk well. A baby who latches on poorly has more difficulty getting milk, especially if the milk supply is not abundant. The milk supply is not abundant in the first days after birth; this is normal, as nature intended, but if the baby’s latch is not good, the baby has difficulty getting the milk. It is for this reason that so many mothers “don’t have enough colostrum”. The mothers almost always do have enough colostrum but the baby is not getting what is there. Babies don’t need much milk in the first few days, but they need some.

Even if the mother’s milk production is plentiful, trying to breastfeed a baby with a poor latch is similar to giving a baby a bottle with a nipple hole that is too small—the bottle is full of milk, but the baby will not get much or will get it very slowly—so the baby sucking at the breast may spend long periods on the breast or return to the breast frequently or not be happy at the breast, all of which may convince the mother she doesn’t have enough milk, which is most often not true.

When a baby is latching on poorly, he may also cause the mother nipple pain. And if, at the same time, he does not get milk well, he will usually stay on the breast for long periods, thus aggravating the pain. Too often the mothers are told the baby’s latch is perfect, but it’s easy to say that the baby is latched on well even if he isn’t. Mothers are also getting confusing and contradictory messages about breastfeeding from books, magazines, the internet, family and health professionals. Many health professionals actually have had very little training on how to prevent breastfeeding problems or how to treat them should they arise. Here are a few ways breastfeeding can be made easier:

The baby should be skin-to-skin with the mother and have access to the breast immediately after birth

The vast majority of newborns can be skin-to-skin with the mother and have access to the breast within minutes of birth. Indeed, research has shown that, given the chance, many babies only minutes old will crawl up to the breast from the mother’s abdomen, latch on, and start breastfeeding all by themselves. This process may take only a few minutes or take up to an hour or longer, but the mother and baby should be given this time (at least the first hour or two) together to start learning about each other. Babies who “self-attach” run into far fewer breastfeeding problems. This process does not take any effort on the mother’s part, and the excuse that it cannot be done because the mother is tired after labour is nonsense, pure and simple.

The baby should be kept skin to skin with mother as much as possible immediately after birth and for as much as possible in the first few weeks of life

Incidentally, studies have also shown that skin-to-skin contact between mothers and babies keeps the baby as warm as an incubator (see paragraph on skin-to-skin contact, below, and the information sheet The Importance of Skin-to-Skin Contact). It is true that many babies do not latch on and breastfeed during this time but generally, this is not a problem, and there is no harm in waiting for the baby to start breastfeeding. The skin to skin contact is good and very important for the baby and the mother even if the baby does not latch on.

Skin-to-skin contact helps the baby adapt to his new environment

The baby’s breathing and heart rate are more normal, the oxygen in his blood is higher, his temperature is more stable and his blood sugar higher. Furthermore, there is some good evidence that the more babies are kept skin-to-skin in the first few days and weeks of life (not just during the feedings) the better their brain development will be. As well, it is now thought that the baby’s brain develops in certain ways only due to this skin-to-skin contact, and this important growth happens mostly in the first 3-8 weeks of life.

A proper latch is crucial to success. This is the key to successful breastfeeding

Unfortunately, too many mothers are being “helped” by people who don’t know what a proper latch is. If you are being told your two-day old baby’s latch is good despite your having very sore nipples, be sceptical and ask for help from someone else. Before you leave the hospital, you should be shown that your baby is latched on properly and that he is actually getting milk from the breast and that you know how to know he is getting milk from the breast (open mouth wide—pause—close mouth type of suck). See also the videos on how to latch a baby on. There are also video clips of babies younger than 48 hours who are breastfeeding not just sucking. If you and the baby are leaving hospital not knowing this, get experienced help quickly (see also the information sheet When Latching).

Note: Mothers are often told that if the breastfeeding is painful, the latch is not good (usually true), so that the mother should take the baby off and latch him on again and again and again... This is not a good idea. Instead of delatching and relatching, fix the latch that you have as best you can by pushing the baby’s bottom into your body with your forearm. The baby’s head is tipped back so the nose is in ‘sniffing position’. If necessary, you might try gently pulling down the baby’s chin so he has more of the breast in his mouth. If that doesn’t help, do not take the baby off the breast and relatch him several times, because usually, the pain diminishes anyway. The latch can be fixed on the other side or at the next feeding. Taking the baby off the breast and latching him on again and again only multiplies the pain and the damage and the mother’s and baby’s frustration.

The mother and baby should room in together.

There is absolutely no medical reason for healthy mothers and babies to be separated from each other, even for short periods, even after caesarean section. Health facilities that have routine separations of mothers and babies after birth are not doing right by the mothers and babies. Studies showing that rooming-in 24 hours a day results in better breastfeeding success, less frustrated babies and happier mothers date back to the 1930’s. Too often, irrelevant excuses are given why baby should be separated from the mother. One example is that the baby passed meconium before birth. A baby who passes meconium and is fine a few minutes after birth will be fine and does not need to be in an incubator for several hours’ “observation”.

Separation of mother and baby so the mother can rest. There is no evidence that mothers who are separated from their babies are better rested. On the contrary, the mothers are better rested and less stressed when they are with their babies. Mothers and babies learn how to sleep in the same rhythm. Thus, when the baby starts waking for a feed, the mother is also starting to wake up naturally. This is not as tiring for the mother as being awakened from deep sleep, as she often is if the baby is elsewhere when he wakes up. If the mother is shown how to feed the baby while both are lying down side by side, the mother is better rested.

The baby’s feeding cues

The baby shows long before he starts crying that he is ready to feed. His breathing may change, for example. Or he may start to stretch. The mother, often being in light sleep in sync with her baby, will wake up, her milk will start to flow and the calm baby will usually go to the breast contentedly. A baby who has been crying for some time before being tried on the breast may refuse to take the breast even if he is ravenous. Mothers and babies should be encouraged to sleep side by side in hospital. This is a great way for mothers to rest while the baby breastfeeds. Breastfeeding should be relaxing, not tiring.

Bathing

There is no reason the baby needs to be bathed immediately after birth and bathing can be delayed for several hours. Immediately after birth, the baby can be dried off but it is not a good idea to wash or wipe off the creamy layer on the baby’s skin (vernix) that has been shown to protect his delicate skin. It is best to wait at least until the mother and baby have had a chance to get breastfeeding well started, with baby coming to the breast and latching easily. Furthermore, diapering a baby before a feed is not advised as it often causes the baby to become upset. Mothers are sometimes told diapering will help the baby to wake up. It is not necessary to wake the baby for feedings. If the baby is skin-to-skin with the mother, the baby will wake when ready and search for the breast. A baby who is feeding well will let the mother know when he is ready for the next feed. Feeding by the clock makes no sense.

Artificial nipples should not be given to the baby

There seems to be some controversy about whether “nipple confusion” exists. Thus, in the first few days, when the mother is normally producing only a little milk (as nature intended), and the baby gets a bottle (as nature intended?) from which he gets rapid flow, the baby will tend to prefer the rapid flow method. Babies like fast flow. You don’t have to be a rocket scientist to figure that one out and the baby will very quickly. By the way, it is not the baby who is confused. Nipple confusion includes a range of problems, including the baby not taking the breast as well as he could and thus not getting milk well and/or the mother getting sore nipples. Just because a baby will “take both” does not mean that the bottle is not having a negative effect. Since there are now alternatives available if the baby needs to be supplemented (see the information sheets Lactation Aid, and Finger and Cup Feeding) why use an artificial nipple? Using a lactation aid, finger feeding or cup feeding to supplement when the baby does not need a supplement is only marginally better than using a bottle to supplement.

No restriction on length or frequency of breastfeedings

A baby who drinks well will not be on the breast for hours at a time (see the video clips of very young babies getting milk very well). Thus, if the baby is on the breast for very long periods of time, it is usually because he is not latching on well and not getting the milk that is available. Get help to fix the baby’s latch, and use compression to get the baby more milk (see the information sheet Breast compression). Breast Compression works very well in the first few days to get the colostrum flowing well. This, not a pacifier,not a bottle, not taking the baby to the nursery or nurses’ station, will help. Babies often feed frequently in the first few days of life—this is normal and temporary. In fact, babies tend to feed frequently during the first few days especially in the evening or night-time. This is normal and helps to establish the milk supply and facilitate mother’s uterus returning to normal. Latching a baby well, compressions, and maintaining skin to skin contact between mother and baby helps this transitional period to go smoothly.

Supplements of water, sugar water, or formula are rarely needed

Most supplements could be avoided by getting the baby to take the breast properly and thus get the milk that is available. If you are being told you need to supplement without someone having observed you breastfeeding, ask for someone to help who knows what they are doing. There are rare indications for supplementation, but often supplements are suggested for “convenience” or due to outdated hospital policies. If supplements are required, they should be given by lactation aid at the breast (see the information sheet Lactation aids), not cup, finger feeding, syringe or bottle. The best supplement is your own colostrum. It can be mixed with 5% sugar water to give more volume if you are not able to express much at first. It is difficult to express much at first because even though there is usually enough for the baby, expressing is not always easy when there is not a lot of milk, as is expected in the first few days. Formula is hardly ever necessary in the first few days. (See our GamePlan for Protecting and Supporting Breastfeeding in the First 24 hours of Life and Beyond, which can be ordered at ibconline.ca.

Free formula samples and formula company literature are not gifts

There is only one purpose for these “gifts” and that is to get you to use formula. It is very effective and it is unethical marketing. If you get any from any health professional, you should be wondering about his/her knowledge of breastfeeding and his/her commitment to breastfeeding. “But I need formula because the baby is not getting enough!” Maybe, but, more likely, you weren’t given good help and the baby is simply not getting the milk that is available. Even if you need formula, nobody should be suggesting a particular brand and giving you free samples. Get good help. Formula samples are not help.

Under some circumstances, it may be impossible to start breastfeeding early.

However, most “medical reasons” (maternal medication, for example) are not true reasons for stopping or delaying breastfeeding, and you are getting misinformation. See the information sheets Medication and Breastfeeding and also Illness and Breastfeeding. Get good help. Premature babies (see the information sheet Premature Baby and Breastfeeding) can start breastfeeding much, much earlier than 34 weeks of age that seems to be the rule in many health facilities. Studies are now quite definite that it is less stressful for a premature baby to breastfeed than to bottle feed. Unfortunately, too many health professionals dealing with premature babies do not seem to be aware of this (see the information sheet Premature Baby and Breastfeeding).

Not latching/Not breastfeeding?

If for some reason baby is not taking the breast, then start expressing your colostrum by hand (often much more effective than using even a hospital grade pump) should be started within 6 hours or so after birth, or as soon as it becomes apparent baby will not be feeding at the breast. see the information sheet When the Baby Does Not Yet Latch On.

Written and revised (under other names) by Jack Newman, MD, FRCPC, 1995-2005 
Revised Jack Newman MD, FRCPC, IBCLC and Edith Kernerman, IBCLC, 2008, 2009

This handout may be copied and distributed without further permission, on the condition that it is not used in any context in which the WHO code on the marketing of breastmilk substitutes is violated.

The Importance of Skin to Skin Contact

There are now a multitude of studies that show that mothers and babies should be together, skin to skin (baby naked, not wrapped in a blanket) immediately after birth, as well as later.

The baby is happier, the baby’s temperature is more stable and more normal, the baby’s heart and breathing rates are more stable and more normal, and the baby’s blood sugar is more elevated. Not only that, skin to skin contact immediately after birth allows the baby to be colonized by the same bacteria as the mother. This, plus breastfeeding, are thought to be important in the prevention of allergic diseases. When a baby is put into an incubator, his skin and gut are often colonized by bacteria different from his mother’s.

We now know that this is true not only for the baby born at term and in good health, but also even for the premature baby. Skin to skin contact and Kangaroo Mother Care can contribute much to the care of the premature baby. Even babies on oxygen can be cared for skin to skin, and this helps reduce their need for extra oxygen, and keeps them more stable in other ways as well (See kangaroomothercare.com) (See the information sheet Breastfeeding your adopted baby).

To appreciate the importance of keeping mother and baby skin to skin for as long as possible in these first few weeks of life (not just at feedings) it might help to understand that a human baby, like any mammal, has a natural habitat: in close contact with the mother (or father). When a baby or any mammal is taken out of this natural habitat, it shows all the physiologic signs of being under significant stress. A baby not in close contact with his mother (or father) by distance (under a heat lamp or in an incubator) or swaddled in a blanket, may become too sleepy or lethargic or becomes disassociated altogether or cry and protest in despair. When a baby is swaddled it cannot interact with his mother, the way nature intended. With skin to skin contact, the mother and the baby exchange sensory information that stimulates and elicits “baby” behaviour: rooting and searching the breast, staying calm, breathing more naturally, staying warm, maintaining his body temperature and maintaining his blood sugar.

From the point of view of breastfeeding, babies who are kept skin to skin with the mother immediately after birth for at least an hour, are more likely to latch on without any help and they are more likely to latch on well, especially if the mother did not receive medication during the labour or birth. As mentioned in the information sheet Breastfeeding—Starting out Right, a baby who latches on well gets milk more easily than a baby who latches on less well. See the video clips of young babies (less than 48 hours old) breastfeeding. When a baby latches on well, the mother is less likely to be sore. When a mother’s milk is abundant, the baby can take the breast poorly and still get lots of milk, though the feedings may then be long or frequent or both, and the mother is more prone to develop problems such as blocked ducts and mastitis. In the first few days, however, the mother does have enough milk, but because it is not abundant, as nature intended, the baby needs a good latch in order to get that milk. Yes, the milk is there even if someone has proved to you with the big pump that there isn’t any. How much does or does not come out in the pump proves nothing—it is irrelevant. Many mothers with abundant milk supplies have difficulty expressing or pumping more than a small amount of milk. Also note, you can’t tell by squeezing the breast whether there is enough milk in there or not. And a good latch is important to help the baby get the milk that is available. If the baby does not latch on well, the mother may be sore, and if the baby does not get milk well, the baby will want to be on the breast for long periods of time worsening the soreness.

To recap, skin to skin contact immediately after birth, which lasts for at least an hour (and should continue for as many hours as possible throughout the day and night for the first number of weeks) has the following positive effects. The baby:

• Is more likely to latch on
• Is more likely to latch on well
• Maintains his body temperature normal better even than in an incubator
• Maintains his heart rate, respiratory rate and blood pressure normal
• Has higher blood sugar
• Is less likely to cry
• Is more likely to breastfeed exclusively and breastfeed longer
• Will indicate to his mother when he is ready to feed

There is no reason that the vast majority of babies cannot be skin to skin with the mother immediately after birth for at least an hour. Hospital routines, such as weighing the baby, should not take precedence.

The baby should be dried off and put on the mother. Nobody should be pushing the baby to do anything; nobody should be trying to help the baby latch on during this time. The baby may be placed vertically on the mother’s abdomen and chest and be left to find his way to the breast, while mother supports him if necessary. The mother, of course, may make some attempts to help the baby, and this should not be discouraged. This is baby’s first journey in the outside world and the mother and baby should just be left in peace to enjoy each other’s company. (The mother and baby should not be left alone, however, especially if the mother has received medication, and it is important that not only the mother’s partner, but also a nurse, midwife, doula or physician stay with them—occasionally, some babies do need medical help and someone qualified should be there “just in case”). The eye drops and the injection of vitamin K can wait a couple of hours. By the way, immediate skin to skin contact can also be done after cæsarean section, even while the mother is getting stitched up, unless there are medical reasons which prevent it.

Studies have shown that even premature babies, as small as 1200 g (2 lb 10 oz) are more stable metabolically (including the level of their blood sugars) and breathe better if they are skin to skin immediately after birth. Skin to skin contact is quite compatible with other measures taken to keep the baby healthy. Of course, if the baby is quite sick, the baby’s health must not be compromised, but any premature baby who is not suffering from respiratory distress syndrome can be skin to skin with the mother immediately after birth. Indeed, in the premature baby, as in the full term baby, skin to skin contact may decrease rapid breathing into the normal range.

Even if the baby does not latch on during the first hour or two, skin to skin contact is important for the baby and the mother for all the other reasons mentioned.

If the baby does not take the breast right away, do not panic. There is almost never any rush, especially in the full term healthy baby. One of the most harmful approaches to feeding the newborn has been the bizarre notion that babies must feed every three hours. Babies should feed when they show signs of being ready, and keeping a baby next to his mother will make it obvious to her when the baby is ready. There is actually not a stitch of proof that babies must feed every three hours or by any schedule, but based on such a notion, many babies are being pushed into the breast simply because three hours have passed. The baby who is not yet interested in feeding may object strenuously, and thus is pushed even more, resulting, in many cases, in baby refusing the breast because we want to make sure they take the breast. And it gets worse. If the baby keeps objecting to being pushed into the breast and gets more and more upset, then the “obvious next step” is to give a supplement. And it is obvious where we are headed (see the information sheet When a Baby Has Not Yet Latched).

The Importance of Skin to Skin Contact, 2009© 
Written and revised (under other names) by Jack Newman, MD, FRCPC, © 1995-2016 
Revised by Jack Newman MD, FRCPC and Edith Kernerman, IBCLC, 2008, 2009©

When Latching

Cross Cradle Position for Left Breast:

• Align baby’s nose so that it does not go past your nipple, or go to the left of your nipple, in other words, your nipple should not be aligned with his chin
• Place your right hand under baby’s face so your four fingers make a pillow for baby’s cheek (keep your four fingers tightly together as if the were stuck together with glue)
• You are now supporting the weight of baby’s head with your hand
• You may want to sit baby’s bottom on you arm as though it were a shelf (this will work in the beginning with a newborn)
• Or you may want to let baby’s bottom fall diagonally a bit and squeeze it against your rib cage with your elbow
• Baby’s body and legs should be wrapped around mother.
• Pull baby’s bottom into your body with the inside/underside of your forearm as if serving baby to you on a platter
• This will bring him toward your breast with the nipple pointing to the roof of his mouth
• Head supported but NOT pushed in against your breast.
• In fact, try to think of it not as bringing baby’s head into or near your breast at all—instead, bring baby’s body into your body and the head will follow, as if serving baby to you on a platter.
• Head should be tilted back slightly so the nose is up and the baby’s chin is coming into the breast while the nose never touches the breast.
• Use your whole arm to bring the baby onto the breast, when baby’smouth is wide.
• Baby’s chin should be far away from Baby’s chest.

WATCH LOWER LIP, aim it as far from base of nipple as possible, so tongue draws lots of breast into mouth. Move baby’s body and head together – keep baby uncurled. If you keep your wrist straight, with baby’s cheek resting on your fingers, then baby’s chin will not bend down toward his chest

Once latched, baby’s top lip will be close to nipple, areola shows above lip. Keep baby’s chin close against your breast.

Need mouth wide before baby moved onto breast. Teach baby to open wide/gape:

• Avoid placing baby down in a feeding position until you are completely ready to latch baby. The longer baby waits while you get ready (undoing your breast, etc) the more frustrated baby gets and the less open baby’s mouth will go.
• move baby toward breast, touch top lip against nipple
• move mouth away SLIGHTLY
• touch top lip against nipple again, move away again
• repeat until baby opens wide and has tongue forward
• Or, better yet, run nipple along the baby’s upper lip, from one corner to the other, lightly, until baby opens wide

Mother’s Posture

• Sit with straight, well-supported back
• Trunk facing forwards, lap flat

Baby’s Position Before Feed Begins

• Nipple points to the baby’s upper lip or nostril

Baby’s Body

• Placed not quite tummy to tummy, but so that baby comes up to breast from below and baby’s eyes make contact with mother’s Support Breast
• Firm inner breast tissue by raising breast slightly with fingers placed flat on chest wall and thumb pointing up (if helpful, also use sling or tensor bandage around breast)

Move Baby Quickly On To Breast

• Head tilted back slightly, pushing in across shoulders so chin and lower jaw make contact (not nose) while mouth still wide open, keep baby uncurled (means tongue nearer breast) lower lip is aimed as far from nipple as possible so baby’s tongue draws in maximum amount of breast tissue

Cautions

Mother needs to AVOID

• pushing her breast across her body
• chasing the baby with her breast
• flapping the breast up and down
• holding breast with scissor grip
• not supporting breast
• twisting her body towards the baby instead of slightly away
• aiming nipple to centre of baby’s mouth
• pulling baby’s chin down to open mouth
• flexing baby’s head when bringing to breast
• moving breast into baby’s mouth instead of bringing baby to breast
• moving baby onto breast without a proper gape
• not moving baby onto breast quickly enough at height of gape
• having baby’s nose touch breast and not the chin
• holding breast away from baby’s nose (not necessary if the baby is well latched on, as the nose will be away from the breast anyway)

Also see videos of latching and latching in other positions.

When Latching, 2009© 
Written and revised (under other names) by Jack Newman, MD, FRCPC, © 1995-2016 
Revised by Jack Newman MD, FRCPC, IBCLC and Edith Kernerman, IBCLC, 2008, 2009© 

This handout may be copied and distributed without further permission, on the condition that it is not used in any context in which the WHO code on the marketing of breastmilk substitutes is violated.