Clinical Reference Systems: Pediatric Advisor 10.0
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Babies who are breast-fed have fewer infections and allergies during the first year of life than babies who are fed formula. Breast milk is also inexpensive and served at the perfect temperature. Breast-feeding becomes especially convenient when a mother is traveling with her baby. Overall, breast milk is nature's best food for young babies.

How Often to Feed

The baby should nurse for the first time in the delivery room. The second feeding will usually be at 4 to 6 hours of age, after he awakens from a deep sleep. Until your milk supply is well established (usually 4 weeks), nurse your infant whenever he cries or seems hungry (demand feeding). Thereafter, babies can receive enough milk by nursing every 2 to 2-and-1/2 hours. If your baby cries and less than 2 hours have passed, he can be rocked or carried in a frontpack. However, waiting more than 2-and-1/2 hours can lead to swollen breasts (engorgement), which decreases milk production. (Feeding less frequently is OK at night, but no more than 5 hours should pass between feedings.)

Your baby will not gain adequately unless he nurses eight or more times per day initially. The risks of continuing to nurse at short intervals (more often than every 1 and 1/2 hours) are that "grazing" will become a habit, your baby won't be able to sleep through the night, and you won't have much free time.

How Long Per Feeding

Nurse your baby 10 minutes on the first breast and as long as he wants on the second breast. Your goal is to have your baby nurse for a total of about 30 minutes at each feeding. Often you will need to stimulate your baby before she will take the second breast. Remember to change the breast you start with each time.

Once your milk supply is well established (about 4 weeks after birth), 10 minutes of nursing per breast is fine when you are in a hurry (since your child usually gets over 90 percent of the milk in this time). However, try not to nurse for periods shorter than 20 minutes. Your baby needs the calories. Shorter feedings may lead to a need for more frequent feedings.

How to Know Your Baby is Getting Enough Breast Milk

In the first couple of weeks, if your baby has three to four good-sized bowel movements per day and six or more wet diapers per day, he is receiving a good supply of breast milk. (Infrequent bowel movements are not normally seen before a baby is 1 month old.) In addition, most babies will act satisfied after completing a feeding.

Your baby should be back to birth weight by 10 to 14 days of age if breast-feeding is going well. Therefore, the 2-week checkup by your baby's physician is very important.

The presence of a letdown reflex is another indicator of good milk production.

The Letdown Reflex

A letdown reflex develops after 2 to 3 weeks of nursing and is indicated by tingling or milk ejection in the breast just before feeding (or when you are thinking about feeding). It also occurs in the opposite breast while your baby is nursing.

Letdown is enhanced by adequate sleep, adequate fluids, a relaxed environment, and reduced stress (such as not expecting much housework to get done). If your letdown reflex is not present yet, take extra naps and ask your husband and friends for more help. Also consider calling the local chapter of La Leche League, a support group for nursing mothers.

Supplemental Bottles

Do not offer your baby any routine bottles during the first 4 to 6 weeks after birth because this is when you establish your milk supply. Good lactation (breast milk production) depends on frequent emptying of the breasts. Supplemental bottles take away from sucking time on the breast. If your baby is not gaining well, see your physician or a lactation specialist for a weight check and evaluation.

After your baby is 6 weeks old and nursing is well established, you may want to offer your baby a bottle of expressed milk or water once a day so that he can get used to the bottle and the artificial nipple. Once your baby accepts bottle feedings, you can occasionally leave your baby with a sitter and go out for the evening or return to work outside the home. You can use pumped breast milk that has been refrigerated or frozen.

Extra Water

Babies do not routinely need extra water. Even when they have a fever or the weather is hot and dry, breast milk provides enough water.

Pumping the Breasts to Relieve Pain or Collect Milk

Severe engorgement (severe swelling) of the breasts decreases milk production. To prevent engorgement, nurse your baby more often. Also, compress the area around the nipple (the areola) with your fingers at the start of each feeding to soften the areola. For milk release, your baby must be able to grip and suck on the areola as well as the nipple. Every time you miss a feeding (for example, if you return to work outside the home), pump your breasts. Also, whenever your breasts hurt and you are unable to feed your baby, pump your breasts until they are soft. If you don't relieve engorgement, your milk supply can dry up in 2 to 3 days.

A breast pump is usually not necessary because pumping can be done by hand. Ask someone to teach you the Marmet technique.

Collect the breast milk in plastic containers or plastic bottles because some of the immune factors in the milk stick to glass. Pumped breast milk can be saved for 48 hours in a refrigerator or up to 3 months in a freezer. To thaw frozen breast milk, put the plastic container of breast milk in the refrigerator (it will take a few hours to thaw) or place it in a container of warm water until it has warmed up to the temperature your baby prefers.

Sore Nipples

Clean a sore nipple with water after each feeding. Do not use soap or alcohol because they remove natural oils. At the end of each feeding, the nipple can be coated with some breast milk to keep it lubricated. For cracked nipples, apply 100% lanolin (no prescription necessary) after feedings. Try to keep the nipples dry with loose clothing, air exposure, and nursing pads.

Sore nipples usually are due to poor latching on and a feeding position that causes undue friction on the nipple. Position your baby so that he directly faces the nipple without turning his neck. At the start of the feeding, compress the nipple and areola between your thumb and index finger so that your baby can latch on easily. Throughout the feeding, hold your breast from below so the nipple and areola aren't pulled out of your baby's mouth by the weight of the breast. Slightly rotate your baby's body so that his mouth applies pressure to slightly different parts of the areola and nipple at each feeding.

Start your feedings on the side that is not sore. If one nipple is extremely sore, temporarily limit feedings to 10 minutes on that side.

Vitamins/Fluoride for the Baby

Breast milk contains all the necessary vitamins and minerals except vitamin D and fluoride. Full-term dark-skinned babies and all premature babies need 400 units of vitamin D each day. White babies who have little or no sun exposure (less than 15 minutes of sun exposure twice a week) also need vitamin D supplements. From 6 months to 16 years of age, children need fluoride to prevent tooth decay. For children up to 3 years old who are breast-feeding and not drinking any water, 0.25 mg of fluoride drops should be given each day. This is a prescription item that you can obtain from your child's physician.

Vitamins for the Mother

A nursing mother can take a multivitamin tablet daily if she is not following a well-balanced diet. She especially needs 400 units of vitamin D and 1200 mg of both calcium and phosphorus per day. A quart of milk (or its equivalent in cheese or yogurt) can also meet this requirement.

The Mother's Medications

Almost any drug a breast-feeding mother consumes will be transferred in small amounts to her breast milk. Therefore, try to avoid any drug that is not essential, just as you did during pregnancy.

Some commonly used drugs that are safe for you to take while nursing are acetaminophen, ibuprofen, penicillins, erythromycin, cephalosporins, stool softeners, antihistamines, decongestants, cough drops, nosedrops, eyedrops, and skin creams. Aspirin and sulfa drugs can be taken if your baby is more than 2 weeks old AND not jaundiced. Consult your physician about all other drugs. Take drugs that are not harmful immediately after you breast-feed your child so that the level of drugs in the breast milk at the time of the next feeding is low.

Some of the dangerous drugs that can harm your baby are tetracyclines, chloramphenicol, antithyroid drugs, anticancer drugs, or any radioactive substance. Women who must take these drugs should not be breast-feeding or should request a safer form of treatment. Another group of drugs that should be avoided because they can suppress milk production are ergotamines (for migraine), birth control pills with a high estrogen content (most birth control pills are OK), vitamin B6 (pyridoxine) in large doses, and many antidepressants.

Burping

Burping is optional. Its only benefit is to decrease spitting up. Air in the stomach does not cause pain. If you burp your baby, burping two times during a feeding and for about a minute is plenty. Burp your baby when switching from the first breast to the second and at the end of the feeding.

Cup Feeding

Introduce your child to a cup at approximately 6 months of age. Total weaning to a cup will probably occur somewhere between 9 and 18 months of age, depending on your baby's individual preference. If you discontinue breast-feeding before 9 months of age, switch to bottle feeding first. If you stop breast-feeding after 9 months of age, you may be able to go directly to cup feeding.

Call Your Child's Physician within 24 Hours If:

• Your baby doesn't seem to be gaining adequately.
• Your baby has less than six wet diapers per day.
• During the first month, your baby has less than 3 bowel movements per day.
• You suspect your baby has a food allergy.
• You need to take a medication that is not mentioned in this discussion.
• Your breasts do not become full (engorged) before feedings by the time your baby is 5 days old.
• You have painful engorgement or sore nipples that do not respond to the recommended treatment.
• You have a fever (also call your obstetrician).
• You have other questions or concerns.