Breastfeeding Basics

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In the last 20 years there has been a major change in breastfeeding practice. Most women in the United States initiate breastfeeding. This was not the case 20 years ago when infants were primarily formula fed. Parents understand breastfeeding is best for their infant for both health and nutrition. Breast milk protects infants from gastroenteritis, otitis media, respiratory illness, asthma, allergic problems and eczema or atopic dermatitis. Breastfed infants have a lower incidence of SIDS, obesity, diabetes, celiac disease, inflammatory bowel disease and even some types of leukemia.

Parents worry if their infant is receiving enough milk and if colostrum is enough for their infant. Usually there is no need to worry. Infants have a limited stomach capacity in the first few days of life. On day 1 the stomach can hold 1-2 tsp. (10cc) and this increases to 2 tbl (30cc) by day 3. By 1-2 weeks of life the stomach can hold 2-3 ozs. This is why milk does not need to be available in large quantities from the beginning. Your infant is born with enough nutrients to allow this transition to feeding by mouth to go slowly and successfully. By watching urine and stool output hydration can be monitored. We like to see 2 wet diapers every 12 hours and 1-2 stools on days one and two and 3-12 stools per day after day 3. Some infants skip up to 5 days between stools and this should be monitored by you and your pediatrician but is often normal.

Another way to follow your infant’s hydration is by tracking the weight. Infants often lose up to 7% of their birth weight. This should be expected. Greater weight loss will need to be evaluated. Most infants gain between 3/4 and 1 oz. per day for the first several months and 1/2 oz. after 6 months of age.

If bottle supplementation is needed then use of expressed or pumped breast milk is best. Formula is also reasonable. Most supplementation is in the 1/2 oz. (15ml) range and is given after your infant has breastfed. Advice and support from a breastfeeding consultant here in the office can help you with supplemental options. A few infants tend to have difficulty returning to breastfeeding after a bottle is given. Breastfeeding infants use mostly their posterior tongues to nurse while bottle fed infants suck with their anterior tongues and use less of their cheek muscles. We think this is a reason why some infants have difficulty transitioning back and forth and although this is uncommon it needs to be watched for.

Breastfeeding is recommended for a minimum of 12 months. And women in some industrialized countries nurse their children until 3-4 years of age. Breastfeeding for longer than 12 months does have cumulative benefits for both the child and the mother.

Please refer to other blog entries for more tips on successful breastfeeding.

Breastfeeding Benefits

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An infant breastfed exclusively for more than 4 months has over 70% fewer lower respiratory tract infections in her first year of life. The severity of bronchiolitis is also reduced as is the incidence of otitis media, serious colds and throat infections. There is a protective effect of exclusive breastfeeding for 3-4 months in reducing the incidence of asthma, atopic dermatitis and eczema.

Gastrointestinal tract infections are also reduced by over 60% and the benefits last for 2 months after cessation of breastfeeding. The risk of inflammatory bowel disease is reduced as is the risk for obesity, childhood leukemia and lymphoma. Breastfeeding is also associated with a 36% decrease in the risk of sudden infant death syndrome (SIDS) and it has been calculated that more than 900 infant lives per year may be saved in the United States if 90% of mothers exclusively breastfed for 6 months.

Neurodevelopmental outcomes are also improved for infants exclusively breastfed for 3 months or longer. Breastfed infants have improved outcomes of intelligence scores and teacher’s ratings. These same benefits are seen for preterm infants as well as a lower rate of serious infections.

For the mother there is decreased postpartum blood loss and a lower frequency of postpartum depression. Breastfeeding for longer than 12 months is associated with a 28% decrease in breast cancer and ovarian cancer.

To help you with breastfeeding we do not support policies following delivery that interfere with early skin-to-skin contact or the supplement of water, glucose water or formula without a medical indication. We also do not restrict the amount of time an infant can be with her mother or feeding duration. We also do not endorse unlimited pacifier use. Pacifier use during the newborn period can be helpful for specific medical indications such as pain reduction and for calming purposes for drug exposed infants. Pacifier use should be delayed until breastfeeding is well established at 3 to 4 weeks after birth.

Schedules and Elimination

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Every first time parent wonders how often their infant needs to be fed. Overall most infants thrive on feedings every 2-4 hours.  Frequent feedings every 2 hours will reduce the amount of time needed for a mother’s milk to come in. Studies show milk will come in a day earlier with an every two hour schedule rather than every 4 hours. The first 6 to 8 hours after delivery a mother may need to rest and allow the nursery staff to feed her infant due to the strenuous hours prior to delivery. Parents need to consider sending their infant to the nursery for the first 6-8 hours after delivery. This allows both parents to sleep. The nursery staff can bring the infant to the mother’s room for a feeding during this time for breast feeding and can feed the infant in the nursery if formula fed. Everyone must understand, the newborn feeding schedule should not exhaust the mother. Adequate sleep, nutrition and fluid intake are the first steps in maternal self-care.

Frequent nursing during the newborn period is associated with greater breastfeeding success as well as higher maternal prolactin levels which increases milk production and greater overall milk intake with greater infant weight gain by age 2 weeks.

Infants are born well hydrated. They have just completed one of if not the most turbulent day they will experience in their lives. Many are too tired to suck and others are slow to learn the latch and suck muscle routines. Breast milk does not come in for at least several days and during this time the colostrum production although important in terms of nutrients and immunity is low in terms of volume. Over half of all babies will lose at least 5% of their birthweight by day three after delivery. This weight loss is to be expected and infants are not stressed by this loss. If there is any sign of low blood sugar by history or exam, your infant will have sugar levels checked several times a day. This is done by pricking her heel for a small blood sample. If needed, early feedings with formula or breast milk will be given.

Many parents wonder if a feeding schedule should be used. Most grandparents were raised under the belief that scheduled feedings were best for infants. Interval feeding is no longer recommended. The American Academy of Pediatrics and the World Health
Organization do not support timed interval feeding schedules. The best approach
is to breastfeed an average of 8-12 times a day. If your infant is formula feeding the same advice is given. Feed frequently and watch for signs of hunger including rooting, restlessness, increased alertness or hand sucking and hand to mouth movements.

Feeding duration varies between infants. Try not to spend longer than 20 minutes for each feeding. Some infants eat faster than others. If your infant falls asleep during a feeding it is best to stop and restart when she shows signs of hunger. Feeding for extended periods will tire most infants and parents. A feeding schedule is a marathon and not a hundred yard dash.

The most important sign of adequate formula or breast milk intake is urine output and the character of the urine.  The urine color should be clear or pale yellow like dilute lemonade. Stool output is extremely variable and ranges from 1-2 times per day to 6-8 or more times per day. Breastfed infants frequently will have a bowel movement with each feeding. Formula fed infants tend to stool less frequently than breast fed infants. Breastfed infants may skip 1 or more days between bowel movements and show no signs of discomfort since the breast milk is absorbed so well by their digestive tract.
Formula fed infants who miss days usually will show some signs of gas and discomfort. The key is patience. No suppositories are needed and no medical intervention needs to be pursued as long as the infant is feeding well and overall doing well.  If your infant does not have a bowel movement in the first 24 hours of life she needs to be watched closely for any obstruction symptoms.

Stools in the first several days will be like black tar. They then change to transitional dark to yellow green seedy stools and eventually to wet mustard stools for breast fed infants. Formula fed infants have more formed yellow to brown stools. Breast milk stools are less odiferous than formula fed stools.  Infants who require soy formula due to milk protein or lactose sensitivity tend to have stools less frequently then infants fed regular
formula. Infants with lactose tolerance problems tend to have loose watery and at times explosive stools when given lactose containing formulas. Maternal diet will effect breast milk but rarely causes feeding and digestion problems for the infant. If specific food intake by the mother causes gastrointestinal issues for the infant then maternal diet adjustments should be made.