Breast-Feeding Questions

• Breastfeeding questions

Topics Covered for Breast-Feeding

If your baby is healthy, skip the "What to Do" section. Go directly to the topic that relates to your question for advice:

• How often to feed to bring in the milk supply
• Length of feedings to bring in the milk supply
• Length of feedings after milk supply is in
• Signs of adequate milk supply (Do I have enough milk?)
• How to increase milk supply
• Supplemental formula
• When to introduce a bottle
• Extra water
• Severe engorgement (generalized swelling and pain) of both breasts
• Blocked milk ducts (1 or more tender lumps in the breast)
• Sore or cracked nipples
• Mother's medicines
• Mother's smoking or tobacco use
• Mother's diet
• Sick infants
• Sick mother (with illness)
• Normal stools during the first weeks of life
• Normal infrequent breast milk stools after 1 month of age
• Leaking breast milk
• Vitamin D for breastfed baby
• Storage of pumped milk
• Burping
• Milk letdown that causes pulling away, coughing or choking
• Cereals and other solids (baby foods)
• When to Call Your Doctor

Expert Reviewers:

Maya Bunik, M.D., Lisbeth Gabrielski, RN, and Marianne Neifert, M.D., Lactation specialists

Call 911 Now

• Can't wake up
• Not moving or very weak
• You think your child has a life-threatening emergency

Go to ER Now

• Hard to wake up
• Too weak to suck

Call Doctor or Seek Care Now

• Age less than 1 month old and looks or acts abnormal in any way
• Dehydration suspected. No urine in more than 8 hours, dark urine, no stool for 24 hours, very dry mouth and no tears.
• Will not breastfeed or takes very little for more than 8 hours
• Looks deep yellow or orange
• Fever in baby less than 12 weeks old. Caution: do NOT give your baby any fever medicine before being seen.
• Your child looks or acts very sick
• You think your child needs to be seen, and the problem is urgent

Contact Doctor Within 24 Hours

• Does not seem to be gaining weight by day 5
• Yellow seedy stools are less than 3 per day. Exception: before 5 days of life while milk is coming in, this can be normal. Also, after 4 weeks of age can be normal.
• Day 2-4 of life and no stool in more than 24 hours
• Wet diapers are less than 6 per day. Exception: before 5 days of life while milk is coming in.
• Day 2-4 of life and no urine in more than 8 hours
• The mother has signs of breast infection (red, tender lump on breast). Exception: localized engorgement.
• You think your child needs to be seen, but the problem is not urgent

Contact Doctor During Office Hours

• Hungry after feedings. Reason: needs a weight check.
• Needs formula during first month. Reason: breastfeeding not going well.
• You have other questions or concerns

Self Care at Home

• Breastfeeding question about healthy baby

Care Advice for Breastfeeding

How Often to Feed to Bring in the Milk Supply:

• Every 1½ to 3 hours for the first month (8 to 12 times per day).
• During the day, wake your baby up if more than 3 hours have passed since the last feeding.
• During the night, wake your baby if more than 4 hours pass without a feeding.
• After 1 month of age, allow your baby to sleep longer. If your baby is gaining weight well, feed on demand and do not awaken for feedings.

Length of Feedings to Bring in the Milk Supply:

• Offer both breasts with each feeding
• Nurse 10 minutes on the first breast. Then, nurse up to 15 minutes on second breast if your baby is actively sucking.
• For each feeding, switch which breast you start on.
• Needing to stimulate your baby to take the second breast is normal.

Length of Feedings After Milk Supply is in: (by day 8 at the latest)

• On the first breast, allow your baby to nurse up to 20 minutes. Reason: to get the high-fat, calorie-rich hind milk.
• You can tell your baby has finished when the sucking slows down. Your breast should feel soft. Then offer the 2nd breast if your baby is interested.
• For each feeding, switch which breast you start on.

Signs of Good Milk Supply: (Is your baby getting enough breast milk?)

• Stools: 3 or more yellow seedy stools per day. Exception: 1 or 2 can be normal while the milk is coming in. Stools should start increasing by day 5 of life. See Care Advice section on Breastfed Stools for more information. Caution: once the milk is in, infrequent stools are not normal. However, it can become normal after 4 weeks of age.
• Urine: 6 or more wet diapers per day. Exception: 3 wet diapers per day can be normal while milk is coming in. Wet diapers should start increasing by day 5 of life. Note: if you aren't sure about the diaper being wet, place a tissue in the diaper.
• Satisfied (not hungry) after feedings
• Breasts feel full before feedings and soft after feedings
• Latching on. It is very important that your baby is latched on right. This way she can get enough milk. Wait for your baby's mouth to open wide. Then have your baby take the nipple and part of areola. Lips must be wide open (like a fish) to get a good latch. Sometimes it helps to push down on the chin.
• Letdown of milk. Look and listen for regular swallowing. This shows that your milk has letdown. Letdown is the release of breastmilk into the milk ducts just before a feeding. It starts after 2 to 3 weeks of nursing. At first, milk letdown may take 60 to 90 seconds of sucking before it starts.

How to Increase Milk Supply:

• Enough sleep (extra naps), reduced stress (ask for help), relaxed environment, good fluid intake
• Drink enough fluids to keep your urine pale yellow in color.
• Usually that means drinking at least 2 quarts (2 liters) of fluid per day.
• Increase how often you nurse. Limit the use of the pacifier.
• Pump the breasts for 10 minutes after each feeding. Do this for a few days (see lactation consultant). Electric breast pumps that are double-sided give the best results.

Supplemental Formula:

• Don't offer your baby any bottles of formula before 3 to 4 weeks old. Reason: it will interfere with creating a good milk supply.
• You should be nursing your baby every 2 hours (start to start). Reason: so your baby can get colostrum after birth.
• There are some exceptions. Medical indications to prevent dehydration or severe jaundice include the following:
• The milk is not in (day 3 - 4) and your baby is very hungry (especially preterms)
• Not enough wet or soiled diapers or
• Your baby is quite jaundiced. Reason: prevents dehydration.
• After every breastfeeding for 1 or 2 days, give expressed breastmilk or formula. Give 1 ounce (30 mL) at a time. Also, see your child's doctor within 24 hours for a weight check.

When to Introduce a Bottle:

• When your baby is 4 weeks old, if your baby is nursing well, offer a bottle of pumped breastmilk (1 ounce or 30 mL). Do this once a day. This allows him to get used to a bottle and the nipple.
• If you wait too long (such as 8 weeks), many babies will reject bottle feedings.
• Once your baby accepts bottle feedings, use them at least once every 3 days. This ensures that he will continue to accept them.
• Bottle acceptance allows you to leave your baby with a sitter. It's also essential if you plan on going back to work outside the home.
• You can use formula or pumped breast milk that has been refrigerated or frozen.

Extra Water:

• Never give extra water to infants younger than 6 months. Reason: too much water can cause a seizure.
• It's not needed. Reason: breast milk contains 88% water.
• If your baby gets enough breast milk, extra fluids are not needed. They may decrease your baby's interest and ability to breastfeed.

Engorgement (generalized swelling and pain of both breasts):

• Engorgement usually begins 2 or 3 days after your baby's birth.
• Also, can start at any time when breasts are not emptied regularly.
• Breastfeed your baby more often. Do not use pacifiers.
• Remove a little milk before feeding your baby. Hand express or briefly use a breast pump.
• Gently squeeze the areola with your fingers at the start of each feeding. This will soften the areola and help your baby latch on. Milk release won't occur if your baby only latches on to the nipple.
• Pump your breasts when they hurt or when a feeding doesn't help discomfort. Also, pump when you must miss a feeding.
• Use a cold pack on the breasts between feedings. Cold cabbage leaves or a bag of frozen peas works well.
• Call your doctor or lactation consultant if: not better after 24 hours of this treatment.

Blocked Milk Ducts (tender lump in the breast):

• Caused by the breast not being emptied all the way
• Treatment goal: open up the blocked milk ducts
• Breastfeed your baby more often. Do not use pacifiers.
• Before each breastfeeding session, use heat on the breast lump for 5 minutes. Do this with a hot shower, hot bath or heating pad.
• While feeding or pumping, massage the swollen areas toward the nipple.
• Try different breastfeeding positions which may drain the affected area (ducts) better.
• Call Your Doctor If:
• Lump becomes red and very painful
• Fever occurs
• Not better after 24 hours of treatment
• Your baby starts acting sick

Sore or Cracked Nipples:

• Most often, due to friction from not latching on right. Can also be due to a non-areolar grasp on the breast.
• Clean with warm water once daily. Do not use soap which dries out the skin.
• For sore nipples, coat and lubricate nipple and areola with breast milk.
• For cracked nipples, use 100% lanolin after feedings. No prescription is needed. Exception: mother allergic to wool. Hydrogel pads are also good for healing.
• Help your baby latch on to as much of the areola as possible. Do this by compressing the areola. Proper latching-on should prevent nipple injury.
• Prevent the breast from pulling out of your baby's mouth. Support the breast from below during feedings.
• Start feedings on the side that is least sore.
• Limit feedings to less than 10 minutes on the sore side.
• Don't pull your baby off the nipple until she has released her grip. You can break the seal by placing your finger in the mouth between gums.
• Call your doctor if: not better after 24 hours of treatment.

Mother's Medicines:

• It's best to take your medicine at the end of a feeding. Reason: it will be out of your system by the next feeding.
• Most commonly used drugs are safe. Examples are penicillins, erythromycin, cephalosporins, stool softeners, cough drops, nose drops, eyedrops, and skin creams.
• Pain Medicines: acetaminophen (such as Tylenol) and ibuprofen (such as Advil) are safe. Aspirin (325 mg) should not be used. Reason: risk for bleeding. Baby aspirin (81 mg daily) is safe to use for mothers who need it for health problems.
• Do not use decongestants. They can reduce milk production in some mothers. An example is Sudafed.
• Do not use sulfa drugs (Septra and Bactrim) for the first month. They are okay after the baby is 4 weeks old.
• Allergy medicines for allergy symptoms are OK during breastfeeding. Long-acting allergy medicines (such as Zyrtec) are preferred. They can be given as needed once per day at bedtime. Do not use combination products with decongestants.
• Birth control pills can decrease your milk volume. Make sure that your milk supply is well established (6 weeks or more) before starting. If you decide to use birth control, consult your doctor first.
• For all other drugs, call your doctor or check the LactMed Website (listed below).
• LactMed is a drug/lactation website. It provides information regarding the safety of medicines while nursing. It's on Toxnet. Toxnet is the toxicology data website of the National Library of Medicine.
• Infant Risk Call Center. Provides current information on the use of medications during pregnancy and breastfeeding. They answer calls Monday-Friday 8 am - 5 pm Central time. 1-806-352-2519. Website at Infant Risk Center.

Mother's Smoking or Tobacco Use:

• It is best not to use tobacco. But, if you must smoke, you can also breastfeed. Generally, the benefit of giving your baby your milk outweighs tobacco risks.
• The nicotine and its byproducts pass into the breast milk. This may cause your baby not to sleep well and increase the heart rate. It can also cause loose stools. Heavy tobacco use (over ½ pack per day) can decrease your milk supply. It may also affect letdown.
• Smoking cessation aids pose no more problems for the breastfed baby than smoking. Use as directed.
• If you smoke, do not smoke around your baby.

Mother's Diet:

• Foods: eat a diet that is varied and balanced. No special foods should be eaten or not eaten. The effect on the baby of foods in the mother's diet is overrated. Foods eaten in moderate amounts most often cause no effects.
• Honey: honey is safe for breastfeeding moms to eat. It is also safe to use to treat coughing in the mother. Botulism isn't transmitted through breast milk.
• Caffeine: caffeine is found in coffee, tea or soft drinks. Too much caffeine can cause your baby to not sleep well. It can also cause increased crying or even diarrhea. Limit caffeine drinks to two 8 ounce (240 mL) servings per day.
• Alcohol: it is best not to use alcohol during breastfeeding. Too much alcohol can cause your baby to be sleepy. It can also affect your milk letdown. If you must drink, limit to an occasional drink of beer or wine. Max: no more than 1 per day. Nurse your baby before you drink. Wait at least 2 hours before nursing again.

Sick Infants:

• Do not stop breastfeeding for vomiting, spitting up, diarrhea, cough, or jaundice. See the care guide for that symptom.
• Keep breastfeeding when possible.

The Mother is Sick (has an acute illness):

• Continue breastfeeding, even if you have a fever.
• Reason: breast milk carries your antibodies. These can protect your baby from the full-blown infection.
• Try to prevent the spread of infection by good hand washing. Do this after blowing your nose (for colds) or after stools (for diarrhea).
• There are few medical conditions in the mother when breastfeeding is not advised. Some of these are AIDS, Herpes simplex rash (fever blisters) on the nipple/areola, drug abuse and tuberculosis. Talk with your doctor.
• Fever Blisters on Mom's Mouth. Fever blisters (cold sores) on the lips are caused by the herpes virus. Herpes can cause serious infections in young babies. It's safe to continue breastfeeding if they are on your (mom's) lips. But avoid kissing or nuzzling your baby until fever blisters are completely dried up.

Breastfed Stools During the First Weeks of Life:

• Meconium Stools are dark greenish-black, thick and sticky. They are passed during the first 2 days of life.
• Transitional Stools (a mix of meconium and milk stools) are greenish-brown and loose. They are passed day 3 to 4 of life. While breast milk is coming in, babies have about one stool per day. This is usually from day 1 to 4. By day 5, passing black or dark green stools is not normal. Your baby should be seen to make sure your baby is getting enough milk.
• Normal Breastmilk Stools without any meconium present are seen from day 5 on. The stools are runny, mustard-colored and can contain seedy particles. Normal breastfed stools can also be green (caused by bile) or have a water-ring around them, especially during the first month. Reason: rapid transit. Normal breastfed stools are loose (often runny and seedy). Stools are yellow, but sometimes can be green. The green color is from bile. Runny stools can even be bordered by a water ring. This is normal.
• Normal stool size is about half to 1 tablespoon (8 to 15 mL).
• Number of Stools: the number of stools is the best marker for how much breastmilk the baby is getting. On day of life 2 and 3, the baby should pass 1 or 2 stools per day. By day of life 4 or 5, the baby should be passing 3 or more breastmilk stools per day. Once breast-feeding is established, babies normally pass 4 stools per day to 1 after each feeding during the first month of life.
• If breastfed babies get any formula, their stools become greener. They also become more frequent, more formed and odorous.
• Diarrhea. Breastfed stools have changed to true diarrhea if:
• There is a sudden increase in the number of stools
• They have blood or lots of mucus
• Smell bad or have a sudden increase in number
• Your baby feeds poorly, acts sick, or a fever occurs

Normal Infrequent Breastfed Stools After 1 Month of Age:

• Between 4 and 8 weeks of age, some breastfed babies change to normal infrequent stools.
• They can pass 1 large soft stool every 4 to 7 days.
• Reason: complete absorption of breastmilk.
• The longer they go without a stool, the larger the volume that is passed.
• There is no pain or crying with stool passage.

Leaking Breast Milk:

• Leaking milk is a common problem that nursing mothers experience during the first months. Usually, the leaking lessens as supply starts to equal demand. A balance is established between what the baby drinks and what the breasts make. Here's what you can do:
• Keep a regular nursing pattern. Try to not skip or postpone feedings. Reason: more milk leaks from over-full breast.
• Use nursing pads under your bra. You can use pads that can be thrown away or washable pads. Change pads often to keep your nipples dry.
• Shirts with patterns hide milk spots better.
• If this advice doesn't help, ask a lactation consultant for more tips.

Vitamin D for the Baby:

• Breast milk contains all the needed vitamins and minerals except Vitamin D.
• Vitamin D. Starting the first week of life, all breastfed babies need Vitamin D. The dose is 400 IU per day. (AAP Committee on Nutrition 2009). You can use separate Vitamin D drops. Or, you can use Vitamin ADC drops in a dose of 1 mL per day. No prescription is needed.
• Your child needs Vitamin D drops until he drinks enough cow's milk or formula. This is at least 32 ounces (1000 mL) of milk or formula per day. Each 8 ounces (250 mL) contains 100 IU of Vitamin D.

Storage of Breast Milk:

• Freshly expressed breast milk can be kept at room temp for 6 hours.
• Freshly pumped breast milk can be stored for 5 days in a refrigerator.
• Frozen breast milk can be kept 6 months in a refrigerator freezer. Do not store milk in the freezer door (side) shelves. Milk can be kept up to 12 months in a deep freezer. If your ice cream is solidly frozen, the temperature is fine.
• To thaw frozen milk, put the bag of breast milk in the refrigerator. It will take a few hours to thaw.
• For quicker thawing, place it in a pan of warm water. Do this until it has warmed up to the temperature your baby likes. Never warm it up in a microwave or boiling water. This would destroy the protective antibodies.
• After thawing, breast milk can be kept safely in the refrigerator for 24 hours. Do not refreeze.
• After feeding your baby, throw out any remaining milk in the bottle. This milk should be discarded after 1 hour.

Burping:

• You do not have to burp your baby. Burping is an option, but not needed.
• It is not harmful if a baby doesn't burp.
• Burping can lessen spitting up, but it doesn't decrease crying.
• Burping can be done twice per feeding, once midway and once at the end.
• If the baby does not burp after 1 minute of patting, it can be stopped.

Milk Letdown that Causes Pulling Away, Coughing or Choking:

• Sometimes, a milk surge will be more than your baby can keep up with.
• Your baby's reaction will be to pull away from the breast. She may cry, cough or even choke.
• Stop the feeding and let your baby recover.
• Wait until the letdown spray stops before putting her back to the breast.
• Pausing and burping more often may help.
• Prevention: the overactive letdown often occurs in mothers who pump often. So, finish one side all the way. Then only pump the other side enough to get rid of any pain.

Cereals and Other Solids (Baby Foods):

• Breast-fed infants should be started on baby foods at 6 months. First baby foods can be cereals and/or fruit.
• Starting before 6 months is not needed. Starting before 6 months makes feedings messier and longer. Early use of solids can also cause gagging.
• Solids don't increase sleeping through the night for breast-fed infants.
• Caution: delaying solids past 9 months of age is not advised. The delay runs the risk that your infant will refuse solids.

Call Your Doctor If:

• Your baby has trouble latching on
• Your baby does not have a strong suck
• Your baby acts hungry after most feeds
• Your baby is not acting normal
• Breastfeeding is painful
• You think your child needs to be seen
• You have other questions about breastfeeding