Breast - Feeding Questions

Pediatric HouseCalls Online

DEFINITION

• This guideline covers common questions asked about breastfeeding.

Topics Covered

If your infant is healthy, go directly to the number of the topic that relates to your child for specific care advice.

1. Frequency of feedings to bring in the milk supply
2. Length of feedings to bring in the milk supply
3. Length of Feedings after milk supply is in (by day 8 at the latest)
4. Signs of adequate milk supply (Do I have enough milk?)
5. How to increase milk supply
6. Supplemental formula
7. Extra water
8. Severe engorgement (generalized swelling and pain) of both breasts
9. Blocked milk ducts (1 or more tender lumps in the breast)
10. Sore or cracked nipples
11. Mother's medicines
12. Sick infants
13. Sick mother (with acute illness)
14. Normal stools
15. Leaking breastmilk
16. Vitamin D and fluoride for breastfed baby
17. Storage of pumped milk

Consultants:  Lisbeth Gabrielski, RN and Marianne Neifert, M.D., Lactation specialists

See More Appropriate Topic (instead of this one) If

• Formula fed, see BOTTLE-FEEDING (FORMULA) QUESTIONS
• Spitting up is main concern, see SPITTING UP

WHEN TO CALL YOUR DOCTOR

Call 911 Now (your child may need an ambulance) If

• Unresponsive or difficult to awaken
• Not moving or very weak

Call Your Doctor Now (night or day) If

• Your child looks or acts very sick.
• Age under 1 month old and looks or acts sick in any way.
• Signs of dehydration (less than 3 wet diapers/day, pink-colored urine, sunken soft spot and very dry mouth).
• Age under 1 month old and refuses to breastfeed for more than 6 hours.
• Refuses to drink anything for over 8 hours
• Looks deep yellow or orange
• Age under 12 weeks with fever above 100.4 F (38.0 C) rectally

Call Your Doctor Within 24 Hours (between 9 am and 4 pm) If

• You think your child needs to be seen.
• Doesn't seem to be gaining weight by day 5.
• Less than 3 normal-sized, yellow-colored, seedy stools/day (during the first 4 weeks) (EXCEPTION: may not be present while milk is coming in during 1 to 4 days of life.)
• Less than 6 wet diapers/day. (EXCEPTION: 2 wet diapers/day can be normal while milk is coming in during 1 to 4 days of life.)
• The mother has signs of breast infection (red, tender area on breast). (EXCEPTION: localized engorgement.)

Call Your Doctor During Weekday Office Hours If

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

Parent Care at Home If

• Breastfeeding question about healthy child and you don't think your child needs to be seen.

HOME CARE ADVICE FOR BREASTFEEDING TOPICS 1 - 17

1. Frequency of Feedings to bring in the milk supply
   • Every 1½ to 2½ hours for the first month (8 or more times/day). During the day, wake her 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 don't need to awaken for feedings.
2. Length of Feedings to bring in the milk supply
   • Offer both breasts with each feeding.
   • 10 minutes on first breast and up to 15 minutes on second breast if your baby is actively suckling.
   • Alternate which breast you start on.
   • Needing to stimulate your baby to take the second breast is normal.
3. Length of Feedings after milk supply is in (by day 8 at the latest)
   • Allow your baby to nurse as long as she wants to on the first breast (up to 20 minutes) (Reason: to get the high-fat, calorie-rich hind milk).
   • You can tell your baby has finished the first breast when the sucking slows down and your breast becomes soft. Then offer the 2nd breast if she's interested.
   • Alternate the breast you start with at each feeding.
4. Signs of Adequate Milk Supply (i.e. your baby is receiving enough breast milk)
   • 3 or more good-sized, yellow-colored, seedy BMs (bowel movements)/day 
   • EXCEPTION: May not be present while the milk is coming in until day 5 of life Caution: infrequent BMs are not normal in breastfed babies until age 4 weeks
   • 6 or more wet diapers/day (EXCEPTION: 2 wet diapers/day can be normal while milk is coming in - until day 5 of life) Note: if uncertain about diaper being wet, place tissue in diaper
   • Satisfied (not hungry) after feedings
   • Breasts feel full before feedings and soft after feedings
   • The letdown reflex is the automatic release of breastmilk into the milk ducts just before feeding. It develops after 2 to 3 weeks of nursing. Initially, milk letdown may require 60 to 90 seconds of sucking.
5. How to Increase Milk Supply
   • Adequate sleep (extra naps), reduced stress (ask for help), relaxed environment, adequate fluids (1 quart of milk and 1 quart of water per day). (Minimum: one 8 oz. glass of fluid every 4 hours while awake.)
   • Increase the frequency of nursing and minimize the use of the pacifier.
   • Pump the breasts for 10 minutes after each feeding (see lactation consultant).
6. Supplemental Formula
   • Don't offer your baby any bottles of formula before 3 to 4 weeks old (Reason: it will interfere with establishing a good milk supply).
   • EXCEPTION: Medical indications to prevent dehydration or severe jaundice include the following: The milk is not in (day 2 - 4) AND your baby is very hungry (especially preterms), inadequate number of wet or soiled diapers or the baby is quite jaundiced (Reason: prevent dehydration).
   • Method: give 1 oz. of formula after every breastfeeding for 1 or 2 days. Also see your doctor within 24 hours for a weight check.
   • After your baby is 3 to 4 weeks old and nursing is well established, give a bottle of pumped breast milk or 1 oz. formula once daily (Reason: so your baby will accept bottle feedings if need to leave with a sitter or return to work outside the home--the "educational bottle"). If you wait until 6 weeks of age, your baby may be unwilling to try the bottle.
7. Extra Water
   • Never needed (Reason: breast milk contains 88% water).
   • Until the milk comes in (day 3 - 5), a few need supplemental formula, but not water.
8. Engorgement (Generalized swelling and pain of both breasts)
   • Engorgement is most common 48-72 hours after birth
   • Nurse your baby more frequently (avoid the use of pacifiers).
   • Express a little milk before nursing your baby.
   • Compress the areola with your fingers at the start of each feeding to help your baby latch-on. Milk release won't occur if your baby only latches on to the nipple.
   • Pump your breasts, whenever they hurt, a feeding doesn't relieve the pain or when you must miss a feeding.
   • Call your doctor or lactation consultant if: not improved after 24 hours of treatment.

9. Blocked Milk Ducts(tender lump in the breast)

   • Caused by incomplete emptying of the breast
   • Treatment goal: open up the blocked milk ducts
   • Nurse your baby more frequently (avoid the use of pacifiers)
   • After each breastfeeding session, apply heat to the breast lump for 10 minutes (e.g., with a hot shower, hot bath or heating pad).
   • While applying heat, massage the swollen areas toward the nipple.
   • Call Your Doctor If:
     • Lump becomes red and very painful
     • Fever occurs
     • Not improved after 24 hours of treatment
     • Your baby starts acting sick
10. Sore or Cracked Nipples:
    • Uusually due to friction from improper latching on or non-areolar grasp
    • Clean with warm water after each feeding (avoid soap which dries out the skin).
    • Then coat and lubricate nipple and areola with breast milk for sore nipples.
    • For cracked nipples, apply 100% lanolin (no prescription) after feedings.
    • Help your baby latch on to as much of the areola as possible by compressing areola. (Proper latching-on should prevent nipple injury)
    • Prevent the breast from pulling out of your baby's mouth by supporting 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 baby's mouth between the gums.
    • Call your doctor if: not improved after 24 hours of treatment.
11. Mother's Medicines
    • It's best to take your drug at the end of a feeding
    • Most commonly used drugs are safe: e.g. acetaminophen, ibuprofen, penicillins, erythromycin, cephalosporins, stool softeners, antihistamines, cough drops, nose drops, eyedrops, and skin creams.
    • Avoid pseudoephedrine because it reduces milk production in some mothers.
    • Avoid aspirin because of a small risk for Reyes's syndrome.
    • Avoid sulfa drugs until baby is 4 weeks old.
    • For all other drugs, call your doctor.
    • Caffeine and alcohol can cause some symptoms. A high intake of caffeine-containing beverages can cause restlessness, crying or even diarrhea. A few cups of coffee is fine.
    • Excessive alcohol can cause drowsiness. Limit beer or wine to 1 drink per day.
12. Sick Infants
    • Do not discontinue breastfeeding for vomiting, spitting up, diarrhea, cough, jaundice, etc. See the appropriate guideline for that symptom.
    • Continue breastfeeding whenever possible.
13. The Mother is Sick (has an acute illness)
    • Continue breastfeeding, even if you have a fever (Reason: breast milk carries your antibodies which can protect your baby from the full-blown infection).
    • Try to prevent the spread of infection by good hand rinsing, especially after blowing your nose (for colds) or after stools (for diarrhea).
    • Contraindications to breastfeeding are rare: AIDS, Herpes simplex rash (fever blisters) on the nipple/areola, substance abuse and tuberculosis. Talk with your doctor.
14. Breastfed Stools, Normal
    • Meconium stools are dark greenish-black, thick and sticky. They normally are passed during the first 3 days of life.
    • Transitional stools (a mix of meconium and milk stools) are greenish-brown and loose. They are passed day 4 to 5 of life. While breastmilk is coming in (Days 1 to 4), babies may normally pass 1 or 2 stools/day. The may even skip a day. By day 5, passing less than 3 stools per day is abnormal and lactation needs assessment.
    • Normal Breastmilk Stools without any meconium present are seen from day 6 onward. Once breastmilk is in, breastfed babies pass from 3 stools per day to 1 after each feeding during the first month. The stools are runny, mustard-colored and contain seedy particles. Normal breastfed stools can even become green or have a water ring around them during the first month. (Reason: rapid transit)
    • Between 4 and 8 weeks of age, most breastfed babies change to infrequent BMs. They pass 1 soft BM every 1 to 7 days (Reason: complete absorption).
    • Breastfed stools have changed to true diarrhea if:
      • They contain blood or mucus.
      • Develop a bad odor or abruptly increase in number.
      • Your baby feeds poorly, acts sick, or develops a fever.
15. Leaking Breastmilk:
    • Leaking milk is a common problem that nursing mothers experience during the first months of nursing. Usually, the leaking decreases as a balance is established between what the baby drinks and what the breasts make. Here's what you can do:
      • Maintain a regular nursing pattern. Try to avoid skipping or postponing feedings. (Reason: more milk leaks from over-full breast)
      • Use disposable nursing pads under your bra. Change pads frequently to keep your nipples dry.
      • Tops (shirts) with patterns hide milk spots better.
16. Vitamin D and Fluoride for the Baby:
    • Breastmilk contains all the necessary vitamins and minerals except Vitamin D and fluoride.
    • Starting at 4-8 weeks of age, all breastfed babies need to receive 200 IU per day of vitamin D (AAP Committee on Nutrition 2003). Until separate Vitamin D drops become available, use Vitamin ADC drops (over-the-counter) in a dosage of 0.5 ml per day.
    • Continue Vitamin D supplements until your child receives at least 16 oz (500 ml) of formula or cow’s milk per day.
    • Starting at 6 months of age, children who are breastfeeding and not drinking any water (with fluoride) need 0.25 mg of fluoride drops each day to prevent tooth decay. This is a prescription item that you can obtain from your child’s physician.
17. Storage of Breastmilk
    • Pumped breast milk can be stored for 6 days in a refrigerator or up to 6 months in a freezer.
    • To thaw frozen milk, put the container of breast milk in the refrigerator, where it will take a few hours to thaw.
    • For quicker thawing, place it in a pan of warm water until it has warmed up to the temperature your baby prefers. Never warm it up in a microwave or boiling water; this would destroy the protective antibodies.

And remember, contact your doctor if your child develops any of the "Call Your Doctor" symptoms.