Breastfeeding Success in the Hospital

Mothers who receive emotional encouragement and informational support about the positive benefits to their health and the health of their child throughout their pregnancy are more likely to breastfeed after delivery and continue to breastfeed for at least 1 year following delivery. Support and advice are available during prenatal visits and from family and friends but involvement in breastfeeding classes or breastfeeding support group meetings can be very beneficial. Mothers often decide whether to breastfeed very early in their pregnancy. This is not a decision that is made at the end of the pregnancy. Healthcare providers play an essential role in this process. Information and support must be provided as soon as the mother to be is aware she is pregnant. Spousal support and workplace support are also essential.

From the moment of delivery contact between mother and the new infant must be supported if breastfeeding success is to be enhanced. This includes skin-to-skin contact between mother and infant immediately after birth and frequently thereafter. This contact has many physical and emotional benefits for both mother and child. Breastfeeding should be initiated within the first hour after delivery and Vitamin K injection and the application of topical eye ointment should be delayed until after the first breastfeeding.

During the first 48 hours following delivery rooming in should be encouraged and supported. This allows maternal-infant contact. Skin-to-skin contact should also continue to be encouraged and supported. There should not be time restrictions to breastfeeding. Breastfeeding should be frequent. Mother and staff must wake the infant if needed to allow breastfeeding 6 to 8 times on the first day and 8 or more times on the second day. Breastfeeding technique should be observed and close attention given to latch problems.  Formula, water, glucose water, bottles and pacifiers should be discouraged. During the first two days of life the infant’s weight and elimination patterns should be closely monitored.

Breastfeeding success is often linked to an infant’s readiness to nurse, breastfeeding positioning and the infant’s ability to obtain an effective latch. Parents must be aware of cues from their new infant that indicate a readiness to breastfeed. These include sucking on the hand, rooting and smacking of the lips. Mothers must be comfortable with and in their surroundings. Due to body exposure during breastfeeding mothers often feel uncomfortable, anxious or hesitant. Privacy and a well supported chest to chest position between mother and infant are essential. During breastfeeding the goal is for the infant to achieve a wide open mouth position with the tongue down and the entire nipple and some of the areola in the infant’s mouth. While the infant is nursing the mother should look for rhythmic sucking movements and listen for audible throat clicks which indicate her infant is swallowing. As milk production increases this audible swallowing will increase. Initial breastfeeding during the first few days may cause some discomfort. Care must be taken to prevent pain from breast engorgement, an improper latch or skin irritation. Overall, breastfeeding should be pain free.

Breastfeeding Success After Discharge Home

During the first week following discharge home your infant should breastfeed between 8 and 12 times every 24 hours. Some infants may breastfeed more often. Your infant should show signs of being full and satisfied within 30 minutes. You will notice after nursing that your breasts will feel softer and less full. Your infant’s stools will transition from black to green and then become brown and eventually a wet yellow mustard color and consistency. Stool output will gradually increase and near the end of the first week stool frequency may increase to 4 or more stools per day. Often your infant will stool with every breastfeeding. Urine output will also increase to at least 5 times per day and often occurs with every stool.

After arrival home it is important your spouse and all of those who love and care about you provide you the emotional and physical support to allow you to continue to breastfeed. Arriving home with a new baby is a time of joy which can be easily displaced by anxiety and guilt. By asking for support and allowing yourself to receive support you will lessen the chance of fear, guilt or anxiety hindering the development of a secure attachment between you and your infant. If you are having difficulty with milk production or latch seek support and advice from your doctor and seek advice from a Lactation Consultant. Joining a Breastfeeding Mothers support group can also be very helpful.

Every mother must support her own needs. Resting every time the infant rests is a good place to start. A healthy diet and adequate hydration are essential. The use of a pacifier or supplemental formula should continue to be discouraged until adequate milk supply is established. This often takes about 1 month. Occasionally the use of an electric breast pump to encourage milk production will be recommended. Supplemental expressed or pumped breast milk is also occasionally given. During the first week of life 400 IU/day of Vitamin D should be initiated.

During the first 6 weeks of life feeding every 8 to 12 times per day is normal. Some infants may continue to require even more frequent feeding. Night feedings are normal and during growth spurts feeding may be even more frequent. Typical growth spurts occur after 10 days and then after 3 and 6 weeks. These spurts may last for 1-2 days. The more milk your infant takes from your breast the more milk will be produced. This allows milk production to be based on the needs of your child. Your child does know best. Continue to stay well hydrated, eat healthy and use alcohol and caffeine in moderation. No specific food restrictions are necessary. If you are placed on a medication talk to your doctor to make sure it is safe to continue to breastfeed. Very few medications prevent breastfeeding.

Continue to avoid formula supplementation if at all possible. The use of formula increases your infant’s risk for illness and changes the gut flora which keeps your child healthy and prevents many gastrointestinal illnesses. Breast milk is the only food your infant needs during the first 6 months of life.

Challenges to Breastfeeding

Although there are many challenges to breastfeeding most of them can be managed with adequate preparation, education and support.

If a mother is HIV positive or is suffering from ongoing drug or alcohol use then breastfeeding is contraindicated. Rare infants with Galactosemia, Tyrosinemia and certain forms of PKU should also receive special formula and not breastmilk.

Mothers should avoid the use of medications, supplements and herbal preparations while breastfeeding unless they are clinically necessary. The vast majority of medications a mother would be prescribed while breastfeeding are safe to use. If a mother is experiencing depression subsequent to the delivery of her infant, it is much safer for the mother to be treated with an anti-depressant medication than for the mother not to be treated. Most anti-depressant medications can be safely used by breastfeeding mothers.

The risk of exposure to a maternal medication during the first few days of breastfeeding is lowest since the volume of maternal milk is lowest at this time. The book titled Medications and Mother’s Milk by Dr. Thomas Hale is a good reference.  Drugs should be chosen for breastfeeding mothers that have a short half-life, high protein binding and low oral bioavailability. Most of the time it is safer and healthier for an infant to continue to breastfeed rather than changing to formula. In some situations discontinuing breastfeeding for a short period of time while continuing to pump and discard breastmilk is necessary. This is seen when a mother is required to receive a radioactive compound to treat her own medical condition.

Jaundice is a common problem seen in infants who breastfeed or formula feed. In the past when an infant who was breastfeeding developed jaundice the breastfeeding was stopped due to concerns breastmilk would increase the jaundice. This is no longer the case. Breastfeeding should continue and if there is not effective milk transfer due to the infant being sleepy or if there is excess weight loss supplemental breastfeeding with expressed breastmilk should be initiated. The level of jaundice should be followed closely especially for premature infants.  Other options include donor human milk or formula. Advice from a Lactation Consultant in these situations is very helpful.

Breast engorgement is a common issue. It can be prevented by frequent breastfeeding and hand or pump expression of milk if engorgement is an issue. Warm compresses before nursing and cold compresses after nursing can also be helpful. On occasion anti-inflammatory medication like ibuprofen can be used.

Mothers are often concerned about inadequate milk supply. This is usually a false perception. It is important this issue is addressed directly and accurate answers given.  Parents must document adequate urine and stool output while monitoring weight gain in the infant. These are the best indicators for adequate milk supply and milk transfer from mother to the infant.

Although smoking is strongly discouraged smoking is not a contraindication to breastfeeding. Breastfeeding reduces the risk of respiratory illness in infants even if the mother is still smoking. A mother should not, however, smoke around her child. Homes, cars and child care locations should all be smoke free.

Some babies who breastfeed can be very fussy. This is usually due to your infant’s temperament and not due to breastfeeding. Providing skin to skin contact, increasing carry time either in your arms or in an infant body carrier and increasing the frequency of breastfeeding can often help. Walking with your infant is helpful as are swaddling, swaying and making soft white noise shushing sounds.  Avoid excessive stimulation due to sights, smells and sounds and do not overly stimulate with motion. A final option is to encourage sucking on your finger or a pacifier if your infant is over age 1 month.

Another challenge to the new breastfeeding mother is sore nipples. Time and patience are essential. Soreness can frequently be avoided by improving your infant’s position and latch during feeding. Superficial fungal or bacterial infections can also occur but these are uncommon. Talk to your doctor and medication can be prescribed if required. If there are signs of a fungal infection (yeast) then treatment of both infant and mother is necessary. Antifungal ointment can be applied to your nipples after each feeding and continued until you are symptom free for 3-4 days. Your infant should be treated with oral mycostatin (nystatin) drops which can be prescribed by the doctor. These can also be applied to your nipples after nursing. Your infant may show white plaques in the mouth and on the tongue. This is called thrush. All pacifiers should be washed well in hot soapy water and nystatin can be applied to the pacifier. Other treatments that can be considered for your infant include oral 0.5% Gentian Violet that is applied to your infant’s mouth one time each day for three days. This can cause staining of clothes and skin. Always check to see if your infant has signs of a yeast diaper rash that is common when your child has thrush. If this is present then treatment with an OTC medication such as clotrimazole 2-3 times per day is needed.

Mastitis is common when your breast is not emptied after nursing. This can lead to pain, redness and swelling of the breast. Weaning is not recommended. The best treatment is frequent breastfeeding to “empty the breast.” Continuous warm compresses are helpful as is soft breast massage prior to nursing. Pumping can be used if breastfeeding is too painful. Anti-inflammatory medication such as ibuprofen can be helpful and antibiotics are prescribed for you if there is pain and fever over 12 hours in duration.

Breastfeeding is Best

Breastfeeding is best for both mom and baby. Everyone knows breast milk is the best nourishment for a newborn infant. It protects your infant from infection, is easily digested, makes your baby smarter and lowers your child’s future risk of developing asthma, allergies, diabetes, obesity and Sudden Infant Death Syndrome. Benefits are not just for the infant.  There are also clear benefits for the mother who breast feeds. It decreases a mother’s risk of heart disease, high blood pressure and diabetes as well as lowering your future risk for developing breast, uterine and ovarian cancer.

Besides these physical benefits there are cognitive and developmental benefits for both mother and baby.  Mothers who breast feed experience a physical and emotional union with their child. This fosters secure attachment, supports self-regulation and healthy eating patterns and enhances maternal fulfillment and emotional satisfaction. Babies who are breastfed have a developmental advantage over formula fed infants.

Another benefit that is easily overlooked is the benefit to the father. Fathers who learn about breastfeeding and become a true partner with their spouse strengthen their relationships with both mother and baby and improve the success of breastfeeding.

The more you know and learn about breastfeeding prior to delivery the more successful the breastfeeding experience will be for both you and your child. Including your spouse in this discovery and learning process is also beneficial.  Breastfeeding is natural but it is also a learned behavior.  Support from family, friends, workplace and your social and healthcare networks are vital but the most important advice is to always expect the best.  Guidance and advice can help you eliminate fears which often lead to anxiety and breastfeeding difficulty. Taking a breastfeeding class, joining a breastfeeding support group and seeking consultation with a lactation consultant or your pediatrician all are helpful. Tailoring your support to your individual needs prepares you best.

During the first hour after delivery it is important to initiate breastfeeding. The nursing staff will be there to guide and support you. Skin to skin contact with your infant is important as is body and head position.  In the days following delivery your milk will come in and your nipples will become less tender.  You and your infant will discover one another. You will become comfortable with making sure your infant rests her chin and nose on your breast and opens her mouth wide with lips turned out. You will learn how to recognize a good latch and watch and listen for rhythmic and deep sucks with interspersed bursts and pauses. Listen for deep swallows rather than sharp clicks and make sure her cheeks are not sucked in. Patience and support are the best therapy.

After discharge make sure you have a breastfeeding toolkit nearby when you nurse. It should be packed with all the important items you might need including water, burp cloths, clean baby clothes, cleansing wipes, nursing pads, fresh diapers, petroleum jelly, plastic disposal bags, hand sanitizer, a soft blanket and pillow, healthy snacks, a music player and lanolin. Drink plenty of fluids and eat healthy.  Nurse on demand and do not watch the clock.  Learn to recognize your infant’s cry, movements and facial expressions. Exercise, adequate sleep and stress reduction techniques all help. Exclusive breastfeeding is best but if due to medical concerns you are unable to breastfeed then remember formulas are nutritious, safe and healthy and you should never feel shame or guilt for not nursing due to medical or personal considerations.

Exclusive breast feeding through 6 months of age is best. At 6 months complementary feeding can start. Most parents begin with infant cereal mixed with breast milk and then progress to vegetables, fruits and pureed meats. Complementary foods are not meant to substitute for breast milk. Continuing breastfeeding through age one to two years and beyond is best.  Providing breast milk for your child is one of the greatest gifts parents can provide.

Breastfeeding Basics

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

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

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.