Breastfeeding Guide

A HELPFUL GUIDE TO BREASTFEEDING With Additional Information Dedicated to Feeding Multiples

TABLE OF TABLE OF contents contents Introduction .............................................................................................. 4 Summary ..................................................................................................... 50 Before Breastfeeding .............................................................................. 7 Publications for Parents...................................................................... 50 Your Breasts ........................................................................................... 7 A Helpful Guide to Breastfeeding Multiple Babies ......................51 Common Questions About Breastfeeding .......................................8 Breastfeeding Multiple Babies .......................................................... 52 Planning Ahead .................................................................................... 55 Beginning to Breastfeed ........................................................................ 9 If All Babies Remain with You in the Hospital ..............................57 If Your Babies Are Admitted to the NICU ......................................59 Breastfeeding Positions and Techniques .........................................14 If Your Babies Are Separated ............................................................. 61 Correct Latch-on .................................................................................. 14 Other Questions About Breastfeeding Multiples ..........................62 Breastfeeding Positions ...................................................................... 16 Appendix ..................................................................................................... 67 Other Breastfeeding Information .....................................................18 For More Information ......................................................................... 67 Common Concerns in the First Weeks .............................................23 References ............................................................................................. 69 When Your Baby Cries ........................................................................ 23 Feeding Log ........................................................................................... 70 Caring for Yourself ............................................................................... 28 Your Notes .................................................................................................. 72 Sore Nipple Conditions....................................................................... 32 Expressing and Storing Breast Milk ..................................................36 Expressing Breast Milk ....................................................................... 36 Storing Your Breast Milk .................................................................... 40 Special Breastfeeding Situations ......................................................41 Common Concerns in the Later Weeks ............................................42 Breast Refusal Causes and Solutions .................................................45 While You Breastfeed ............................................................................. 46 2 3

BREASTFEEDING your baby INTRODUCTION Breastfeeding can help protect your baby Breastfeeding is one of nature’s ideal from common early childhood illnesses such systems. Just as mothers are capable of as colds, ear infections, and diarrhea, An important responsibility of new parents is to see nourishing their babies in the womb, most especially during the early weeks and are able to nourish their babies at the breast. months of their life. Your breast milk is that their baby gets nourishment to grow and Breast milk is the ideal food for babies. If you suited to your baby. It changes from hour breastfeed your baby for a short time, to hour and day to day, depending on develop properly. When you breastfeed, you’re part remember, even small amounts of your your baby’s needs, and it’s already at the milk can make a significant contribution right temperature. of the majority of parents who have chosen the to your baby’s health. Breastfeeding also has advantages for you. The benefits of breastfeeding can begin right Many mothers feel that nothing else creates preferred method of feeding babies. The first section after your baby’s birth. A baby put to your a closer bond between themselves and their breast immediately after the experience of babies. Most babies can be quickly calmed of this booklet is intended mainly for parents of being born is comforted by the warmth and and reassured by being put to their mother’s touch of your body. Hearing the familiar beat breast. Breastfeeding may also help your full-term babies. But even if your baby is premature of your heart and the sound of your voice uterus (womb) return to its pre-pregnancy and finding a place to suck will be calming. It size. And studies show that women who or has special medical needs, you can still breastfeed will ease your baby’s introduction to the breastfeed may be less likely to get breast outside world. and cervical cancer. and may find this information helpful. 4 5

BEFORE breastfeeding Although breastfeeding is natural, many You should discuss your questions or YOUR BREASTS moms are surprised when problems arise concerns early with your obstetrician or Changes. During pregnancy, breasts and they and their babies don’t seem to your baby’s pediatrician. They can refer you increase in size as their milk-producing cells know what to do automatically. It takes time, to a breastfeeding specialist, who often is an grow and multiply. In fact, many women say patience, and support for both mother and international board-certified lactation that tender breasts were one of the very first baby to learn how to breastfeed. As a new consultant (IBCLC), or to the local chapter signs they were pregnant—their body was Figure 1. The breast. mother, you want to understand as much as of La Leche League. preparing to make milk for their baby. possible before you begin. Some major Though breast milk is widely accepted as the As your pregnancy progresses, you may points discussed in this booklet are: best nutrition for newborns, there are notice that the areola (the dark skin around • How to get off to a good start situations in which parents can’t provide it the nipple) is larger and darker (see Figure 1). • How your milk is made or choose not to. There’s no shame in You may also see small bumps on the areola, • H ow to position your baby correctly either—and remember, fed is best! Whether called Montgomery glands. These produce a at the breast you provide breast milk for a short time or substance that softens the skin, may slow the breastfeed exclusively for an extended growth of bacteria, and has a scent that may • H ow to tell if your baby is getting period, you are making an investment of guide the baby to nourishment. enough to eat time and commitment that can be rewarding Some women are afraid that if they • Common concerns of br eastfeeding for both you and your baby. breastfeed, their breasts will sag. But the mothers number of pregnancies, heredity, and aging • Breastfeeding in special situations are responsible for sagging breasts, Milk cells (alveoli) It takes time, patience, and not breastfeeding. Where milk is produced support for both mother Previous breast surgery. If you have had Milk ducts and baby to learn how any type of breast surgery, it is important to Tubes through which milk travels to breastfeed. discuss this with your health care Nipple professional or a certified lactation consultant. Some surgeries can interfere with breastfeeding because needed nerves Areola and ducts may have been damaged. In many The dark area around the nipple cases, though, mothers find they are able to Milk pockets (sinuses) breastfeed successfully. Where milk collects The only way to know if you can breastfeed is to try. Even if the end result is that you stop breastfeeding or can’t fully breastfeed, you should feel very good about your efforts. Any amount of breast milk that your baby receives will be of benefit. 6 7

COMMON QUESTIONS BEGINNING about breastfeeding to breastfeed Can I breastfeed if my breasts are How can I breastfeed in public? HOW BREAST MILK IS MADE The small amount of colostrum also makes it small? Yes. The size of your breasts depends It can be very convenient for you to breastfeed Human milk is made by special cells inside easier for your newborn baby to practice the largely on how much fatty tissue they contain, when you are away from home with your baby. your breasts (see Figure 1). The milk comes breastfeeding skills of sucking, swallowing, not the amount of milk-producing tissue. Most All states have laws that specifically allow from these cells, moves down the milk ducts, and breathing at the same time, in rhythm. women can make enough milk for their babies women to breastfeed in any public or private and flows through the nipple openings to By the time your baby masters the rhythm, no matter what size their breasts are. location. For more information, see the your baby. For your body to continue to your milk supply increases to match their Are there any special foods I should National Conference for State Legislatures produce milk after your baby is born, two increasing appetite. eat? The only requirement is that you eat a (www.ncsl.org), which details breastfeeding important things must happen. First, nipples healthy, well-balanced diet. Some mothers find laws in all 50 states. To feel more comfortable, must be stimulated along nerve pathways so GETTING OFF TO A GOOD START that their babies are upset by certain foods, and you can place a blanket or shawl over your chest your body gets the message to make more For the first hour or two after your baby is they need to eliminate just those foods from and shoulder so that the breast cannot be easily milk. The stimulation is provided either by born, they will likely be wide awake and their diet. But this should be evaluated on an seen. It may be helpful to practice this at home the baby’s sucking at the breast in the proper ready for their first breastfeeding. When individual basis with your physician before you first. Many stores have areas where mothers can position or by expressing your milk yourself. some babies are put skin-to-skin with their cut any particular food out of your diet. breastfeed in private, or you might consider The second key to continued milk production mothers shortly after birth, they will attach ducking into a fitting room to breastfeed. You is frequent and complete emptying of milk (“latch on”) to the breast on their own. Other Can I lose weight while I am may be more at ease trying these things if you from the breasts. The more milk you remove, mothers and babies need a little assistance breastfeeding? Breastfeeding may help breastfeed in front of a mirror at home—and the more milk you will make (see “Breastfeeding before this latching can occur. some mothers get back to their pre-pregnancy note how little of the breast can actually be seen. weight more quickly than mothers who are not How can the rest of baby’s family be positions and techniques,” page 14, and “How do you breastfeeding. The hormones involved in involved? Other members of the family can express your milk?” page 36). breastfeeding cause the uterus to contract, provide breastfeeding support and THE FIRST MILK which helps it shrink in size. It is important that encouragement. For example, studies have Colostrum is the name of the first milk to the foods you eat are healthy, so that you can shown that with the partner’s help and come from the breasts. The breasts begin to keep up your energy while breastfeeding. It is support, breastfeeding is more successful and make colostrum—a thick, sticky, yellowish or you, not your baby, who will suffer if your diet is continues longer. Other caregivers can also not a good one. Many mothers find that eating make sure you get enough to eat and drink, white substance—in the 16th week of small, frequent, nutritious snacks and meals, and they can do many things to help care for pregnancy. Because colostrum is small in and drinking plenty of fluids, will help them lose the baby so that it is easier for you to amount, some first-time mothers think weight more quickly. Breastfeeding mothers can breastfeed. they “don’t have any milk” for their baby. participate in an exercise program as soon as But a little colostrum goes a long way! their health care professional gives the OK. If the first feeding doesn’t go perfectly, Do I need to stay at home to breastfeed? It is the ideal food for your newborn to start be patient. You are both new at this. No. Breastfed babies are easy and convenient to on for several reasons. First, it contains a Instead, breastfeed as often as possible take along with you. When you have recovered large amount of antibodies, which will help during your hospital stay. Studies have from the birth of your baby and are ready to go protect your baby from illnesses during the shown that mothers who stay with their out, all you need is your baby and the diaper first months of life. Second, it is a very babies after birth have greater success bag. If you need to go out without baby, you can concentrated food source, high in protein at breastfeeding. By being together, you soon express your milk and leave it for someone and minerals. recognize each other’s signals and get off to a else to feed while you are gone (see “Expressing great beginning! and storing breast milk,” page 36). 8 9

Let the hospital staff know that you want your These important practices will help ensure a HOW MILK GETS TO YOUR BABY baby to get breast milk. Ordinarily, no water or great start for breastfeeding. You will not feel your colostrum or milk formula supplements should be necessary. Care of your breasts. A daily shower with being delivered to your baby at first. Some Sucking on a bottle or pacifier may “confuse” warm water is all the cleaning that is necessary signs that they are getting food from your your baby and make it harder for them to for your breasts. Avoid using soap on your breasts are that you may feel sleepy or breastfeed. If it is medically necessary for your breasts; it can dry the skin and wash off the thirsty or have uterine cramps after your baby to receive a supplemental feeding, your natural softener. baby has been breastfeeding for a few health care professional will discuss options minutes. If the cramping you feel while with you. Some health care professionals recommend breastfeeding is uncomfortable, it may be It is also important to feed your baby during that women with flat or inverted nipples helpful to empty your bladder right before the night right from the start. Studies have wear breast shells inside their bras 30 you breastfeed. These after-birth pains help shown that new mothers may not sleep well minutes before feeding. Breast shells are your uterus (womb) shrink back to its when their newborn babies are out of their specially designed, hard plastic cups with a former size. They are often gone by the time sight and hearing. Further, feeding your baby hole for the nipple. They provide constant, your baby is about a week old. at night helps to prevent your breasts from slight pressure to draw the nipple out so that attaching to the breast will be easier As your milk changes, breastfeeding becoming overly full (engorged) and helps for the baby. A certified lactation consultant probably will go something like this: baby your milk supply to increase sooner. Offer or your health care professional can discuss latches on to the breast and sucks for up to a your baby the breast frequently, at least 8 this and other possible remedies to help if few minutes. Then the milk-making cells in times in every 24-hour period. Do not limit latch-on is a problem. your breast move milk down the ducts to the number of minutes they are allowed to After the first few days of nursing, your your baby. This is called the let-down or nurse on each side. The time it takes to get YOUR CHANGING MILK breasts may become engorged (larger, fuller, milk-ejection reflex. If you watch the way the milk they need varies greatly from During the first few weeks, your milk and slightly tender) due to increased milk your baby sucks, you will see a change from baby to baby. If you take your baby away from changes in the way it looks, in how much of it production and the increased blood flow to short, choppy sucking to long, pulling sucks. the breast after a certain number of minutes, there is, and in what it provides your baby the breasts. This fullness can last several You should also be able to hear them they may not have gotten enough breast milk. (see Figure 2). For example, mature milk days and may interfere with the baby’s swallowing your milk. Some mothers see It is important to allow your baby to “tell” you looks thinner than colostrum but is actually attaching to the breasts properly (see milk dripping from the other breast as their when the feeding is over. Most babies will higher in calories. “Engorgement,” page 30). baby breastfeeds, indicating that the milk usually do this themselves by coming off the Many mothers are more comfortable if they has let down. breast when they have had enough. wear a well-fitting and supportive bra, but it When your baby is about 2–3 weeks old, you is not absolutely necessary to do so. may know your milk is letting down when Figure 2. Your changing milk. you feel different sensations in your breasts. However, if you don’t feel anything, don’t Colostrum Transitional milk Mature milk worry. It is perfectly normal not to feel your milk let down at every feeding. 0 1 2 3 4 5 DAYS AFTER BIRTH 10 11

ENOUGH MILK FOR YOUR BABY It is a good idea to have your baby weighed at How much milk you make is determined Probably the #1 concern of new breastfeeding your pediatrician’s office during the first by how often and how well your baby mothers is whether their babies are getting week. There are some clues to tell you breastfeeds. In other words, the supply is enough breast milk. During your hospital stay, whether your baby is getting enough. influenced by your baby’s need. To maintain an you may see from your baby’s medical record How much a baby takes in affects how adequate milk supply, it is very important to that they have lost weight. The first weight much comes out. Keeping track of the only breastfeed for the first 4 weeks of baby’s that newborns lose is extra fluid. You will see number of wet and soiled diapers will help life. your baby’s eyes get less puffy each day, and you know whether your baby is getting A healthy, full-term newborn who is • After feeding, your baby does not display they will be able to look around more easily. enough (see the list of guidelines starting on the breastfeeding effectively at least 8 times a day feeding/hunger cues (for example, trying to It is normal for newborns to lose up to 7% next page). should need no additional fluid other than put their hands into their mouth, rooting, of their birth weight before beginning to breast milk. Feeding a baby water or formula sucking on their hands) and seems satisfied for gain. Most babies are at home by the time LITTLE TUMMIES TAKE TIME can lessen their desire to nurse, which will an average of 1 to 3 hours between feedings they begin to gain weight. It is also perfectly TO GROW upset the supply-and-demand system. Do not • Your breasts feel softer after a feeding (once normal for your baby not to be back up to Your baby’s tummy is about the size of a small marble at give your newborn water unless instructed by your milk supply has increased) their birth weight until they are 2 weeks old. birth. After 3 days, it’s about the size of a ping-pong your physician. Be aware that babies who ball, but still can’t hold much.1 receive bottle feedings, especially just as they • Expect at least 1 wet diaper the first day In the first few days, after recovering from Day 1 are learning to breastfeed, may have difficulty of life and three on days 2 and 3. Look for birth, your baby may “wake up” and seem to going to the breast afterward. Bottle feeding more wet diapers on days breastfeed infrequently or to be fussy. Many encourages babies to use a sucking technique 4 and 5. Your baby should wet at parents think this means their baby is not that is different from the one used for least 6 diapers every day after about getting enough breast milk. That is not true. breastfeeding. A baby may get used to the bottle 6 days of life. This is a normal stage of the breastfeeding Marble • Your baby is passing yellow, seedy, runny cycle, but—unfortunately—some new *e and then later refuse the breast. z parents don’t realize that. It is the most i Day 3 stools, starting on day 3 or 4. If baby is not y s Even though you cannot see the amount of passing any stools or is still passing common reason they give for introducing m breast milk that goes into your baby, there are m meconium (thick and black or dark green supplemental bottles in the early days. u other signs that suggest they are getting s t ’ stools), check with their pediatrician. y enough to eat. Your baby is likely getting Sometimes this fussy period coincides with b a • Your baby is gaining enough weight, as shown the normal softening of the mother’s breasts B enough milk if: after the initial engorgement is gone. Mothers by the scales in the health care office. A baby may then question the adequacy of their milk • They breastfeed at least 8 times in every should stop losing weight by about the fourth supply. The fussiness is only temporary, and 24-hour period or fifth day after birth, and should be back to does not necessarily mean you don’t have • They usually breastfeed for 10 minutes or birth weight by 2 weeks of age. If you have any enough milk. Some mothers worry that their Ping-pong ball more in a rhythmic suck/pause/suck pattern concerns about your baby getting enough milk is too “weak” for their babies. milk, contact their health care professional or Remember: Your milk is right for your Until they are about 4 months old, your baby’s tummy • You can hear frequent swallowing after baby a certified lactation consultant. They may can only hold small amounts of milk at a time. Too much has been at the breast for a few minutes. weigh your baby and make specific baby! If you let your baby finish the first milk during feedings can lead to things like fussiness, Once your milk supply has increased or suggestions. breast before moving on to the second, you gas, or spit-up. “come in”—by day 3 or 4—the swallowing is can be sure they get the especially nutritious * These models may be useful only as a representation of the high-fat milk at the end of the feeding. average breast milk intake during the early newborn period.1 much easier to hear. Reference: 1. Spangler AK, et al. J Hum Lact. 2008;24(2):199-205. 12 13

BREASTFEEDING positions and techniques CORRECT LATCH-ON Of course, everyone worries whether they are doing it “right.” Here are some signs that The way your baby “latches on,” or attaches, to the breast is probably one of the most will tell you if your baby is not latched on correctly: important things for both of you to learn. For correct latch-on, your baby’s mouth needs to be • Your nipples are sore during the whole feeding or become sore as the positioned over the pockets of milk that are located about 1 to 1½ inches behind the nipple feeding continues (see Figure 1). There are 2 important reasons for this. First, your baby will get the most milk when they are positioned there. Second, you will be less likely to have sore nipples. • You can hear clicking or smacking noises when baby sucks The following tips will help you latch your baby on to your breast properly (as shown in • They are having trouble latching on and come off the breast repeatedly Figure 3). If you have any questions about positions and techniques, ask your nurse or after only a few sucks a certified lactation consultant. • They fall asleep after a very few minutes of nursing • Both you and your baby should be in comfortable positions. You should be able • Baby’s cheeks are dimpling in with each suck to draw a straight line from the baby’s ear to shoulder to hip. • They have too few wet diapers and stools (see page 13) • Gently lift and support your breast, with your fingers below and your thumb on top • Your baby “acts hungry” all the time by being very fussy of the breast and well away from the areola (Figure 4). This is sometimes called the C-hold or sandwich hold. • Gently stroke the baby’s bottom lip with your nipple in a downward motion several times. Pause to see if baby’s mouth opens. Repeat this until your baby opens their mouth very wide to ensure sufficient breast tissue is in baby’s mouth. (Babies breastfeed not nipple feed) (Figure 4). • Then quickly pull the baby onto your breast so that their nose, cheeks, and chin are all slightly touching the breast (Figure 5). • Baby latches on and begins to suck. If baby’s nostrils are blocked while nursing, you can pull baby’s bottom upward and closer toward you so that their head will move back slightly, giving them more space to breathe. Or you can lift your breast slightly with the hand that is supporting it. Your baby will pull their head away from the breast if breathing is difficult. Figure 3. Proper breastfeeding position. Figure 4. The C-hold and baby’s mouth wide open. Figure 5. Baby correctly latched on. 14 15

BREASTFEEDING positions There is no one right breastfeeding front of your nipple. Use a pillow to support LYING DOWN position. In fact, there are several positions your arm. If correctly positioned, your baby’s This is a comfortable alternative position, especially at that can be comfortable for you and your body should form a straight line from ear to night or when sitting is uncomfortable. Lie on your side, baby. You may want to try several to see shoulder to hip. Tuck baby’s lower arm using one pillow to support your head and another along which work best for you, or alternate based around your waist, out of the way. your back. Your head and neck should be comfortably upon where you are or time of day. For THE FOOTBALL HOLD propped up with pillows. Or lie on your side with one arm example, you may enjoy a cradle hold sitting Like a running back cradles a football, you’ll bent under your head and the other hand supporting your in a comfortable chair during the day but cradle your baby under your arm. This lets breast. Put a pillow or rolled-up blanket behind your baby’s prefer to nurse lying down at night. Some you see if they are latching on properly. This back. Lay your baby next to you on the bed so their mouth experts even suggest changing positions to position often is preferred by moms who: is opposite your nipple. When baby opens their mouth prevent your baby from latching on and wide, they are ready to latch on. applying pressure to the same spot every • Have large breasts time. • Are concerned about latch-on Figure 8. Lying down to breastfeed. THE CRADLE HOLD • Have a small or premature baby • Are sore from a cesarean birth THE CROSSOVER HOLD Place pillows at your side to support your This position often is preferred by moms who are having elbow and your baby’s bottom. Tuck baby trouble with latch-on and by moms with small or into the side of your waist. Place baby’s head premature babies. It lets you see the latch-on more clearly in the palm of your hand. Support the base of than the traditional cradle hold. Hold your baby across their head between your thumb and your body in the arm opposite the breast from which they forefinger. If your baby doesn’t seem will be feeding. Baby’s position will be the same as in the comfortable, place a soft blanket between cradle hold, but you’ll use your other arm to hold them. your hand and their head for padding. Your baby should be level with your breast, with their body turned toward you. (Some mothers find they can tuck baby’s bottom into the crook of their arm.) Figure 9. The “crossover” hold. LAID BACK BREASTFEEDING Figure 6. The “cradle” hold. Preferred by moms who may have had a c-section or a very forceful letdown (baby gags often) this position uses gravity to help baby latch onto the breast and it takes pressure Sit in a comfortable chair with support for off of an incision. Mom lays back at a 45 degree angle either in bed or in a chair. Baby is your arms and back. Try not to hunch your positioned tummy to tummy with mom. Support baby with your arm across their back. Bring shoulders. Support your breast with your baby towards the breast and when they open wide, latch them onto the breast. hand in a cupped C-shape. Place your baby across your stomach, tummy to tummy. Your baby’s head should be in the bend of your elbow, and their mouth should be directly in Figure 7. The “football” or “clutch” hold. 16 17

OTHER BREASTFEEDING information WAKING YOUR BABY TO FEED • Try frequent (at least every 2 or 3 hours) your baby, rest assured that it won’t last HOW LONG SHOULD A Your baby may spend so much time sleeping daily feedings if your baby’s pattern is to forever. And both you and your baby will FEEDING LAST? during the first 2 or 3 days of life that you will sleep longer during the day and to nurse benefit from these frequent feedings during The length of time that a baby will be at the have to wake them for feedings. The old often at night. It may take a while, but this her first few days of life. breast for a given feeding varies widely from adage, “Never wake a sleeping baby,” is bad can help your baby move into a better day/ baby to baby. Extremes of too little news for a newborn! Another event in the night pattern. HOW OFTEN TO FEED YOUR BABY or too much time can be worrisome. first few days that may make your baby As they get a little older, your once-sleepy Since your newborn’s stomach is very small Generally, most newborns should feed for at temporarily difficult to wake is circumcision. baby will spend more and more time awake. If and breast milk is easily digested, the milk least 10 minutes and they should be able to Most babies sleep very deeply for 6 to 12 it is still necessary to wake your baby to feed, obtained from a feeding will empty from the complete a feeding in about 60 minutes hours after this procedure. you will be more successful if you wake them stomach in about 1 to 2 hours. This means you or less. from a light sleep. If you cannot wake your will need to feed baby often. Frequent It is important for you and your baby to begin Newborn babies have varying levels of sleep baby or they are very sluggish after not eating feedings are also very important to keep up the feeding in a comfortable position so there that range from very deep to very light. During for 5 or 6 hours, call your pediatrician for your milk supply and to assure that your baby is no need to stop too early. In fact, limiting lighter sleep states, you may note your baby advice. gains weight. breastfeeding time may lead to complications making sucking movements or trying to reach • Let your baby tell you when the feeding is such as breast engorgement, decreased milk their fingers to their mouth. These are cues DEALING WITH A FUSSY BABY finished—they will come off the breast on supply, inadequate infant weight gain, and that baby is ready to feed and should need If you keep your baby with you as much as their own infant jaundice. Limiting the duration of only a little stimulation to do so. possible, you will soon begin to see what feeding does not prevent sore nipples. • Many babies’ sleep/awake cycles naturally calms them. Wrapping baby securely in a • Feed your baby whenever they show signs of allow for 8 to 12 feedings a day. During the receiving blanket or holding them upright on hunger, even if they just ate an hour ago. It is daytime, if 3 hours have passed since the last your chest with their skin touching yours may normal for breastfed babies to “cluster feed” feeding, or if your breasts are uncomfortably soothe them. Once your milk supply has in the beginning. This means your baby full, wake your baby to feed. increased and the baby’s tummy is getting may want to be fed several times in a Frequent feedings are also full, they should settle down. Responding to row before taking that nap you had very important to keep up • Talk to, rub, pat, unwrap, or undress your baby’s cries with love and comfort will give anticipated. It does not mean that your baby to wake them. Change baby’s diaper or the message that the world is a safe place. milk supply is low. It is normal your milk supply wash their face with a warm washcloth. It breastfeeding behavior. may take 5 or 10 minutes of this stimulation Being close and warmly snuggled while • As your baby grows, so does their stomach. to wake your baby. sucking at the breast is comforting for a Babies start to feed less frequently because • Many parents make the mistake of putting newborn as they adjust to life outside the they are able to hold a larger amount of food their baby to the breast at the first sign of womb. As an added bonus, your milk supply at each feeding. wakefulness. Then they wonder why their will increase sooner and you will be less likely baby goes right back to sleep! You must to experience engorgement. really wake your baby so they can participate in the feeding for long Another normal behavior of newborn babies, enough to get an adequate amount of although perhaps less common, is to wake up milk. more often than expected. They may seem to be at the breast constantly. If this describes 18 19

• Your baby should breastfeed long enough • If your baby doesn’t seem interested in • Your baby may not burp after every on each breast to get a good flow of milk taking your second breast, offer it first feeding. Even though most breastfed babies and to be satisfied. Allow them to tell you at the next feeding. don’t take in much air while they are when a feeding is over; don’t watch the breastfeeding, it is still a good idea to try clock. Each feeding is like a full-course BOES YOUR BABY NEED EXTRA FLUIDS? burping your baby after they have finished meal. When your baby first breastfeeds No. Unless there is a medical reason for your feeding from the first breast and again after they get a large amount of watery milk. As baby to receive a supplement, they should get the second. If they do not burp after a few baby continues to breastfeed, the fat no other fluids than breast milk. Otherwise, minutes, either continue the feeding or put content of the milk increases until they get just when you are trying to get off to a good baby down to sleep, whichever is to the rich, high-fat milk called hindmilk. start, baby will not go to the breast often appropriate. You will quickly learn your When your baby has had enough of this, enough because their tummy will be full of baby’s needs they will stop feeding, either going to sleep extra fluids. During the first 3 or 4 weeks of and patterns. at the breast or letting go of the nipple and breastfeeding, do not offer water or infant • Your baby may spit up colostrum or milk. It looking very satisfied. Some babies only formula to your baby unless it is necessary or usually looks like a much larger amount nurse on one side per feeding, and that recommended by your pediatrician. than it actually is, so don’t be alarmed. If Figure 11. Breaking the suction. is totally normal. you are concerned about it, speak to their • Try for a burp and offer the second breast Experts recommend that all breastfed health care professional. for as long as baby wants infants begin a vitamin D supplement within • Occasionally, you may need to take your a few days of birth. Vitamin D is necessary CHANGING BREASTS baby off the breast before they are ready to for strong, healthy bones. Check with your • It is ideal to offer both breasts at come off by themselves. Insert a finger into doctor for specific guidelines for your infant. each feeding. But it is even more important baby’s mouth between the gums, far back to to make sure that your baby has enough break the suction, and remove your nipple BURPING YOUR BABY time to finish at from baby’s mouth (see Figure 11). Try burping your baby when you change the first breast before switching sides. breasts and again when the feeding is This is because the fat content of the complete to help remove swallowed air. milk increases the longer the baby breastfeeds. • Hold your baby upright against your • Your baby may be full after finishing the shoulder or lay them across your lap or first breast and refuse the second. If so, stomach, face down. Also, you may begin with that breast at the next feeding. sit your baby on your lap, leaning forward The second breast, from which less (or no) against your hand. Support baby’s chin (see milk was taken at the last feeding, will Figure 10). probably feel fuller when it’s time to • Pat or rub your baby’s back gently, but breastfeed again. If you forgot which side don’t insist if they don’t burp readily you fed from last time, don’t worry; just Figure 10. Common burping position. feed from the side that feels fuller. 20 21

COMMON CONCERNS in the first few weeks IF YOUR BABY PREFERS • If baby fusses when you change their WHEN YOUR BABY CRIES 8:00 am and then begin the next feeding at ONE BREAST position, start with the football hold on the Newborn babies cry for a variety of reasons. 10:00 am. You would say that your baby has While a baby is first learning how to preferred side. Then, after baby has Sometimes they cry a lot when they are fed “every 2 hours.” The length of the feeding breastfeed, it is very common for them to breastfed for a little while, gently slide adjusting to a new situation. For many parents, is not counted.) You may learn that your baby prefer one breast over the other. As most them over into the cross cradle hold at the the first night home from the hospital is is actually breastfeeding the expected number women’s nipples are not exactly the same other breast. frustrating because their baby seems to cry a of times. shape on both sides, baby may find one breast • If you have a breast pump, it may help to great deal. If your baby cries, stay calm and try easier to latch on to. Perhaps the nipple on pump for a few minutes on the less- swaddling, swinging/rocking and/or a white If you are feeding baby for more than an hour at one side fits their mouth better, or maybe the preferred side (see “Expressing and storing noise sound machine to help soothe them. In a time, your nipples are sore throughout the milk flows more freely from one breast than breast milk,” page 36). This may help pull the time, you will be a master at how to calm your feeding, or your baby seems hungry between the other. Your baby may be more nipple out farther and start the flow of baby. Just be patient and know that this meals, you may have a problem with latching comfortable in a certain position. Whatever milk. behavior is completely normal and has on and need to ask for help. The most common the reason, this is a common situation. While • If your baby skips 2 or more feedings in a nothing to do with your breast milk. cause of long, too-frequent feedings and sore learning to feed from both breasts, your baby row on the breast that is not preferred, you nipples is incorrect positioning at the breast. will still get all the nutrition they need from should begin to express your milk regularly Many new parents are advised that it is best to Your baby’s mouth needs to be over the milk one side. (preferably with a hospital-grade electric let the baby “cry it out” or that if they always pockets that are about 1 inch to 1½ inches pump). This will help increase milk pick up their crying baby, they will “spoil” behind your nipple. Here are some suggestions for getting baby production from the less-preferred breast. them. But rest assured that newborn babies to breastfeed from the less-preferred side. If are absolutely unspoilable! By responding to When properly positioned, your baby will get these are not helpful, it is advisable to work • If necessary, continue to express milk from your baby’s cries promptly with comfort, you more breast milk and nipple soreness should with your health care professional or a the less-preferred breast until baby begins are telling them that their needs will be met go away. If this “eating all the time” behavior is lactation consultant. to accept that breast and are helping smooth their transition home. something new, it may be an appetite spurt • Try breastfeeding on the preferred side • If your baby refuses to latch on at all to one IF YOUR BABY WANTS TO BREASTFEED and only temporary (see “Growth spurts,” page until your milk has let down and is dripping side, the use of a hospital-grade electric ALL THE TIME 44). As your baby’s stomach grows, they will from the other side. Then switch baby over. breast pump will ensure that you continue Breastfeeding is more than just providing be capable of eating more at each feeding and, to produce milk in that breast and keep it food. It also provides the comfort of sucking therefore, will need to feed less often. from becoming engorged. It will also help plus the safety and warmth of your arms. to stretch the nipple and make latch-on Remember that because your baby’s stomach As described earlier, breastfed babies more likely. is still very small, they will need to eat 6-8 sometimes “cluster feed” (want to eat several times per day or more for at least the first 4 times in a row during a 2-hour period instead weeks of life. If your baby is a “leisurely” of feeding well only once and then waiting If necessary, continue to breastfeeder—and babies do have different 2 or 3 hours to feed again). Remember: This is express milk from your styles of breastfeeding—it may take them as not a sign that the baby is not getting enough to preferred breast until the baby long as an hour to complete a meal. eat. It is a normal breastfeeding behavior; allow begins to accept that breast your baby to breastfeed as often as they want. To get a true picture of how often your However, if you continue to be concerned, call baby is breastfeeding, write down the time your health care professional or a lactation each feeding begins. Feedings are timed consultant. from the start of one to the start of the next. (Example: you begin to feed your baby at 22 23

JAUNDICE their first few days of life, they will have LATCH-ON CONCERNS • Your baby may be unable to latch on More than half of all newborn babies get fewer stools and may be more prone to Sometimes bringing baby and breast together because your breasts are overfull. If so, jaundice. When a baby is jaundiced, their skin jaundice. can be a challenge. It is important to get help wearing breast shells 30 minutes before and the whites of their eyes have a yellow if you are not able to solve a latch-on problem feedings will encourage your milk to leak, tinge. Most of the time no treatment is Babies may become jaundiced for other on your own. Good sources of help for softening the areola so the baby can grasp needed, and the jaundice will clear up on its reasons. Sometimes it happens when the breastfeeding difficulties may include health your nipple. own. If your baby gets jaundice, the doctor mother’s blood type is different from the care professionals, certified lactation • Some mothers help get the baby latched on may test their blood to make sure the level of baby’s blood type (as in a condition called consultants, other breastfeeding specialists, by squeezing a few drops of milk onto their bilirubin in their blood does not go too high. ABO incompatibility). When this is present, or members of the La Leche League. nipple so the baby can taste the level of bilirubin usually rises faster and the milk While you are pregnant, your body higher than in normal physiologic jaundice. Concerns and possible solutions. (specifically your liver) processes certain When babies have more difficult vaginal If you have difficulty getting your baby to substances for your baby. Bilirubin is one of births, perhaps requiring forceps or a vacuum latch on to the breast, some of these It is important to get help if those substances. When your baby is no extractor, and bruising occurs, jaundice may measures may help you: you are not able to solve a longer physically connected to your blood be more likely to develop. If your baby is born supply, their liver must process bilirubin by prematurely or is sick after delivery, they also • It is ideal to give your baby nothing but latch-on problem on your own itself. It usually takes a few days for a baby’s may be more prone to jaundice. breast milk until your baby’s breastfeeding body to be able to do this quickly and is well established. When baby is having efficiently. In the meantime, the bilirubin There is another kind of jaundice, appearing trouble latching on, an artificial nipple may builds up in their bloodstream, causing the later (at least 5–7 days after birth), that is only make things worse. If your baby needs • Sometimes a baby tries repeatedly yellow skin and eyes. This most common kind called breast milk jaundice. It occurs in about a supplemental feeding, it may be best to to feed, with no success, and begins to cry of jaundice is called physiologic jaundice. It is 1 of every 250 babies. Although the exact try a method other than a bottle (see frantically and act frustrated. usually noticed about the second or third day cause is still unknown, it usually resolves on “Alternate feeding methods,”page 41). If this happens with your baby, take them of life and is generally gone by the time the its own without hurting the baby while you • If you have flat nipples, try gently rolling away from the breast and calm baby is a week old. continue to breastfeed. them between your thumb and index finger them for several minutes before you begin to try to make them more erect. Pulling again. Skin to skin is a great way to calm The main way your baby gets rid of bilirubin You should notify your baby’s health care back slightly on the breast tissue or using baby before resuming or trying to is through stools. The more stools baby has professional if you notice your baby has the C-hold (see Figure 4) can also help the breastfeed again. (and the quicker they get rid of those first jaundice, especially if it develops at less than nipple protrude for easier latch-on. • If you have been trying to latch baby on in tarry stools called meconium), the less likely 24 hours of age, if it lasts longer than • Using a breast pump just before a feeding one position and it is not working, change it is that their bilirubin will go high enough to 7 days, or if it extends to your baby’s arms and will help soften the areola and pull your to another position. Even if it is one that require treatment. Of course, in order for legs. Make sure you contact the doctor’s office nipple out for easier latch-on. If your baby is didn’t work yesterday, just the fact that you It is important to get help if baby to produce stools, they must eat. if you think your baby is acting sick or unable to grasp the nipple after several tries have changed positions may allow your you are not able to solve a becoming a very sluggish feeder. and requires supplementation, you should baby to latch on. latch-on problem on your Babies who breastfeed frequently and take in begin to pump your breasts regularly with a own more milk are less likely to become jaundiced. hospital-grade electric pump. This will If your baby is breastfeeding poorly during stretch your nipple skin and help increase your milk supply. 24 25

• In some very specific instances, a nipple up. Your baby may be more likely to breastfeed breastfeeding, they should settle down shield may help your baby get positioned onto after a few hours. If you are unable to wake fairly quickly. the breast. However, nipple shields should be them for a feeding after 6 hours, call your used only if your health care professional or pediatrician for advice. If your baby seems to want to feed a great breastfeeding specialist recommends it and deal, be sure they are latched on to the closely monitors your breastfeeding progress. If your baby is still having difficulty latching breast far enough and that you are not setting • Continue to try to put your baby to the breast on by the time they are 1–2 days old, they time limits on how long they nurse on each for a short time several times a day. Do this may have a problem that can be resolved side (see “How often to feed your baby,” page 19). when baby is calm and not frantically hungry, with the help of a lactation consultant. For babies 2 months and older, many experts to maximize your chances of success. You will “MY BABY IS UP ALL NIGHT” recommend that you wake them every 2–3 need lots of support to continue this, so don’t Babies often have their days and nights hours during the day for feedings and let hesitate to call for help. And take heart: it’s mixed up at first. When in the womb, and them wake you on their own schedule at common for women to have challenges mother is up and walking, it is like being in a night. This may encourage baby to with breastfeeding. hammock. They sleep most of this time eventually sleep more during the night than Baby concerns. Sometimes it is your baby when you are pregnant. How often does your during the day. who has a problem that makes it difficult for baby suddenly seem to become active when them to latch on to the breast, even if you you lie down to sleep? Another recommendation is to give your seem to have “perfect” nipples. One of the baby the message that night is for sleeping. It is rare that women cannot produce most common problems is that newborn Many parents find the first or second night Make night feedings “strictly business.” enough milk for their baby. More often it is babies are very sleepy. They are kept tightly home with their new baby difficult. The Keep the lights low and talking and playing the simple, correctable details of swaddled in blankets, often with pacifiers in same baby who seemed to sleep all the time to a minimum. Change baby’s diaper, feed breastfeeding that lead to a low milk supply their mouths, yet we expect them to wake up in the hospital now seems to be awake all them, and put them back to sleep. Remember or to your baby not taking all the milk that is and eat! night! This is temporary. The only to always place your baby on their back, as available. Sleepiness may also be related to your baby’s environment your baby knows outside the recommended for all healthy infants. need to recover from labor and birth. Or womb is the hospital and, although your home is probably quieter and calmer, baby WEIGHT GAIN perhaps you had medicine or an anesthetic needs time to adjust to it. You cannot spoil If your baby has any problems such as not that may temporarily make your baby your newborn by picking them up when they feeding often enough, sucking incorrectly, or difficult to waken or be uninterested cry. Baby will likely make the transition to being extremely sleepy or excessively fussy, One of the most common in feeding. home more smoothly in the security of a or if they are sick, it is possible they are not problems is that newborn Even though your baby needs to recover parent’s arms. getting enough breast milk. Consult your babies are very sleepy from birth, try to wake them to feed at least pediatrician for an evaluation and a weight 8 times in every 24-hour period, to make It may seem that your baby wants to check a couple of days after you return home sure they get enough breast milk. If you keep breastfeed every hour during the night. This from the hospital. If you are worried about baby with you, perhaps skin-to-skin, and commonly occurs just as your milk supply is how much baby is eating, take them in early stimulate them every hour or so to wake them increasing and your baby is making an and ask for help with a breastfeeding plan. adjustment. With cuddling and frequent 26 27

CARING FOR YOURSELF yourself again. No matter how you gave healthy diet. In either case, meals and snacks “Can the food I eat upset my baby?” Getting enough rest. In the early days birth, though, spend at least the first 2 weeks should be as nutritious as possible. Try to The food you eat must first be digested and after having a baby, it is essential that you try at home getting to know your baby and choose a variety of foods from all the absorbed by your body before any substances to get enough sleep. Rest is important for getting breastfeeding off to a good start. food groups. are passed into your milk. This usually takes staying healthy and feeling good—keys to Increase your level of activity gradually, If your diet is poor, 2–6 hours. If you eat dinner at 6:00 pm and successful breastfeeding. Besides lack of using the amount of vaginal bleeding you are it is you who will during, or not long after, a 10:00 pm feeding sleep common to late pregnancy and the having as an indication of whether you are suffer, not your your baby draws up their knees and screams, energy you used in labor and giving birth, doing too much. Do not plan any outings baby. Continue think about what you ate for dinner. your nighttime sleep will be interrupted by more strenuous than a visit to the health taking prenatal baby’s need for frequent feedings. Nothing The only way to be absolutely sure which will bolster your ability to cope during this care professional’s office. Have friends come vitamins if they are food is to blame is to re-create the same time better than adequate rest! to you instead of going to see them, and have recommended by situation and see if baby reacts again. If you others bring your groceries whenever your health feel a particular food is causing your baby Try to take a nap every day, while your possible. care professional. problems, stop eating it for a while. Later, try partner or supportive family members screen What to eat. Many new mothers feel Drinking adequate fluids will help breast a small amount of that food. If your baby visitors and phone calls. “Sleep when the baby discouraged that they are not in the same milk production. Not getting enough liquids doesn’t react, eat more next time. sleeps” is some of the best advice ever given. shape as before their pregnancy. You will lose will negatively affect your milk supply. Make Try to keep your life simple and accept all If your baby seems very fussy, try keeping a offers of help. If friends or family volunteer to some weight right after delivery, but probably a practice of keeping a glass of water or record of what you eat and drink. Discuss this bring you meals, do some household chores, have some left to lose. During the first months other nutritious beverage nearby and with your health care professional to shop for groceries, or care for your other of breastfeeding, some of the “fat stores” that drinking enough to prevent becoming determine if there is an association between children, say “Yes!” You will rest more easily appeared during pregnancy will provide thirsty. Never ignore your thirst. All healthy certain foods and your baby’s symptoms. knowing that these things are being done. energy to support your body as you make milk adults are encouraged to drink 6–8 glasses of Medicines and other substances. for your baby. Therefore, breastfeeding can water per day. If, despite your attempts to rest, you feel actually help you return to the weight you If you need to take medicine or an herbal tired and overwhelmed, reach out to others were before pregnancy, if your food choices supplement for any reason, even an over- for help; don’t keep it to yourself. Try talking are nutritious and the amounts are not the-counter one, check with your health care to your partner, a family member, a excessive. professional to make sure it is all right. If it supportive friend, your childbirth class Drinking extra fluids will turns out that you have been prescribed a instructor, your health care professional, or a Breastfeeding requires the same healthy diet help increase breast milk medicine that may be harmful to your baby, lactation consultant. Sometimes just a phone that is recommended for pregnancy, and production there may be another choice that will work call can help a lot. your body probably will tell you to eat and just as well and allow you to continue to drink often. Many women find that they breastfeed. Make sure the health care Your activities. During the first few need snacks between meals because they get professional who prescribed the medicine weeks after your baby’s birth, you will feel very hungry. It is also common for some knows you are breastfeeding, especially if your energy level slowly returning to normal. women to have a poor appetite for a few days you are expressing milk to feed a premature If you had a surgical delivery (cesarean), it or even weeks after a baby is born. Eating baby. will probably take longer for you to feel like small, frequent meals may help you to eat a 28 29

Caffeine is known to cause fussiness and Engorgement. Sometimes mothers • Gently massage your breast as the baby • If these measures don’t seem to help, a wakefulness in some babies. You may want to experience engorgement as their milk supply breastfeeds to encourage the milk to lactation consultant can discuss other types limit your intake of substances that contain increases, or “comes in.” This usually occurs flow freely of treatments with you caffeine, such as chocolate, coffee, tea, many within the first couple of days. If your • Feed your baby as often as possible (at least soft drinks (not just colas), and some breasts become engorged, they will feel full, every 3 hours), for as long as they will headache, cold, and allergy medicines. swollen, tender, and warm to the touch. You breastfeed, and from both sides, if possible. Because alcohol passes through breast milk to may have swelling that extends up under Unfortunately, baby’s tummy will be baby, many experts recommend that you limit your arms, since you have milk ducts there, getting fuller than it has before and they The best way to prevent or entirely avoid drinking alcoholic beverages. too. The swelling can flatten out your nipple, may wish to shorten the length of feedings engorgement is to breastfeed perhaps making it difficult for your baby to just when you wish they would breastfeed your baby frequently Check with your baby’s health care latch on properly and leading to nipple longer. professional for specific recommendations. soreness. • If your baby doesn’t feed frequently and Mothers who smoke cigarettes may make less vigorously from both breasts, use a breast milk and have problems with milk let-down. The engorgement should be gone, or much pump or hand-express milk after each The American Academy of Pediatrics advises decreased, within 48 hours. If not, it may be feeding from the side baby didn’t feed from. against smoking while breastfeeding because a good idea to get help from a lactation This will help relieve the engorgement and nicotine passes through breast milk to consultant. If engorgement goes unrelieved, keep up your the baby. it can affect your milk supply. milk supply. Babies who are around smoke are more likely The best way to prevent engorgement is to • After breastfeeding, and between feedings, to get respiratory illnesses such as coughs and breastfeed your baby frequently, day and put cold compresses or cloth-covered ice asthma as well as ear infections. There also night, right from the start, making sure that packs on your breasts to reduce the seems to be a connection between passive they are correctly latched on. swelling. Refreezable ice packs or even bags cigarette smoke and sudden infant death of small frozen vegetables, such as peas or syndrome (SIDS). If you do become engorged, the following corn, work well as ice packs because they measures may help: can be wrapped around the breast. Your If you smoke and are unable to stop breasts should soften somewhat after altogether, at least cut down as much as you • Apply warm, moist compresses (hot breastfeeding, but they will still be quite can. Certainly, you do not want to smoke washcloths or towels) just before feeding— hard until the swelling goes down. during feedings because of the possibility for about 5 minutes only. More heat than • Avoid underwire nursing bras; they can put of burns. this may actually increase the swelling. additional pressure on engorged breasts • Massage your breasts, expressing some and increase the risk of plugged milk ducts No breastfeeding mother should ever use milk, to soften the areola so your baby can • If the engorgement is painful, you may illegal drugs of any kind. latch far enough on to your breast. Wearing safely take a mild analgesic to relieve the breast shells for about 30 minutes before discomfort, as recommended by your health the feeding may encourage leaking and care professional soften the areola. 30 31

Sore nipples. Sore nipples are probably the most common complaint in the early days of It may be normal to feel some nipple the first day of nursing, if your nipples burn breastfeeding. A new mother may be surprised at how uncomfortable it is and think about tenderness in the first few days of while feeding or after or between feedings, giving up breastfeeding. breastfeeding—it often peaks around the or if the soreness does not improve after 2 or The following information may help you resolve your sore nipples and go on to breastfeed third day after birth and goes away in the 3 days of consistently trying to correct the your baby for as long as you planned. next several days. But if you feel pain past problem, you should get help from your the first 30–60 seconds after your baby has health care professional or a certified latched on to the breast, if the soreness lactation consultant. SORE NIPPLE keeps getting worse, or if you have pain that conditions starts several days after you begin breastfeeding, something may be happening SYMPTOM POSSIBLE CAUSE that needs more attention. Bruises on skin around nipple Baby is latching on off-center—especially common with flat The most frequent cause of sore nipples is or inverted nipples; mother is using breast pump incorrectly improper positioning of the baby during Crack or scab across center Baby is not latched on correctly; unusual shape latch-on (see “Correct latch-on,” page 14). The 2 of nipple of roof of baby’s mouth most common mistakes new mothers Crack or scab on underside Baby may have lower lip rolled in while sucking make are 1) not waiting for baby’s mouth to of nipple at breast open wide enough before attempting latch-on and 2) not pulling baby far enough onto the Soreness of entire nipple Incorrect latch-on of baby who has very strong suck; breast so that their nose, cheeks, and chin all baby pulling tongue back with each suck (produces touch the breast. “biting” effect); baby curling tip of tongue up; mother Figure 12. Using the side of the index finger to open not breaking suction properly before removing baby The soreness caused by an improper baby’s lower lip. from breast; mother not supporting breast during latch-on is from injury to the nipple and feeding; yeast infection of nipple surrounding skin—blisters, cracks, scabs, Incorrect latch-on. Go back and review Soreness, blisters, bruising, Baby not latching on far enough; mother holding breast and/or bruises. Another cause of nipple “Correct latch-on” (page 14) and or horizontal red stripe on in a way that makes nipple point up or down during soreness can be simple irritation of the “Breastfeeding positions” (page 16). tip of nipple latch-on; baby not sucking properly nipple or surrounding tissue. If the nipple soreness is caused by irritation, the nipple It is possible that the baby latches on Soreness or bruising on top Baby not correctly latched on or not sucking properly skin will be bright pink or red and may burn. correctly in the beginning, but that during of nipple It is possible to have both types of nipple the feeding their mouth slips partly off the soreness at the same time. breast, ending up in the wrong place. If you Burning of nipples during Yeast infection pay close attention, you will be able to tell feedings, right after feeding, It is important to determine what is causing when this happens. Break the suction, and/or between feedings your nipple soreness so that you can correct remove baby, and begin again with a correct Bright red or pink nipples; Yeast infection; skin irritation from friction or from lotion, the problem. The chart on page 30 may help latch-on. Baby should remain snugly against may appear chapped or flaky cream, or soap being used on breasts; improper use you to identify the cause(s). The paragraphs you if you use pillows to support them and of breast pump after the chart describe what to do. Keep in your arms. mind that if it hurts when you breastfeed on 32 33

Sometimes mothers start to experience Unusual shape of roof of baby’s If your nipples are so sore that you cannot Yeast infection. Yeast is a fungus that can problems with sore nipples after their milk mouth. Babies come in all shapes and sizes, tolerate the pressure of your bra or clothes, cause symptoms in your nipples and milk supply increases and they are engorged. and this includes difference in the inside of consider using special breast shells ducts and your baby’s mouth and diaper Engorgement leads to very full breasts their mouths. If your baby’s palate (the roof specifically designed for sore nipples. These area. The most common symptoms in babies and taut nipples that are a challenge of their mouth) has a dome shape, you may have large nipple openings and a hole for are white patches in the mouth and/or a red, for the baby to latch on to. Refer to have unusually sore nipples in the beginning promoting air circulation inside your bra. raised diaper rash. In mothers, possible “Engorgement” (page 30) for help if of your breastfeeding experience. You need symptoms include bright red or pink nipple this happens. to be especially careful about positioning, skin that may be accompanied by flaky or Baby not sucking properly. See the and you may benefit from wearing breast itching skin or a burning sensation. section on signs of incorrect latch-on (page shells 30 minutes before feedings and Be sure to wash your Sometimes the only symptom is extreme 15) to help you decide if your baby is putting breast milk on the nipple skin to breasts only with warm soreness during the whole feeding when sucking properly. promote healing. The nipple skin should water baby appears to be well latched on. Both you heal eventually, and sore nipples will cease and your baby must be treated at the same Baby rolling bottom lip under. Try to to be a problem. time or the infection will come right back. It get baby to open their mouth wider during Skin irritation: red, pink, chapped, can be passed back and forth between you latch-on. If this fails to correct the problem, flaky. Be sure to wash your breasts only during feedings. If you suspect that you pull down gently on baby’s chin with the If you are using a breast pump, be sure to or your baby has a yeast infection, call side of your index finger after they have with warm water unless you are told to start out gently each time. Don’t pull too your health care professional. Both you latched on, and their lip should open out (see do otherwise by your baby’s pediatrician. hard (with a hand pump) or turn the setting and your baby may require medication Figure 12). Soaps and some lotions or creams may of an electric pump too high (see “Using a breast to cure yeast infection. irritate the skin and make problems pump,” page 38). Not breaking suction when taking worse. However, there is a hypoallergenic You may need to see your health care baby off breast. If you need to take your lanolin made especially for breastfeeding professional or a lactation consultant if these baby off the breast before they have finished mothers that is soothing and healing and suggestions do not solve the problem. a feeding, be sure to insert a finger into the does not need to be removed before your side of their mouth to break the suction baby breastfeeds. Other things that may before removing your breast. Make sure you cause irritation include cologne, deodorant, have carefully washed your hands before hair spray, and powder. Try putting cool, breastfeeding. moist compresses on your breasts after breastfeeding. Or try expressing some milk after feedings and apply that to your nipple. Wearing a bra that is too tight or one with a seam that rubs the nipple may also cause irritation. 34 35

EXPRESSING AND STORING breast milk What is expressed breast milk? If your baby was born prematurely or has EXPRESSING MILK BY HAND It is your milk that has been collected in a other special medical needs, their • Wash your hands container by using a pump or your hand. pediatrician may advise to delay the start of • Place one hand at the edge of the areola of Your milk can vary in color and consistency breastfeeding. You can express your milk so one breast, with your thumb above and according to the time of day it is expressed that it can be fed to your baby until your fingers below the areola and the as well as the age of your baby. The amount breastfeeding is possible. nipple in the center (see Figure 13). Your you are able to express in one session will If your baby is having difficulty latching on fingers and thumb should not be moved on also vary, depending on when your baby was due to flat or inverted nipples, an electric the skin, as this leads to pinching of the last fed, how old they are, how much breast pump may help to correct that. Some nipple. Pull back toward your chest, press practice you’ve had at expressing, and how mothers need the extra breast stimulation your thumb and fingers together to squeeze much milk you are producing. If your baby is that pumping provides in order to maintain the breast, and then roll them forward a newborn, it is normal to get only small their milk supply due to an infant’s weak or toward your nipple. Hold your thumb and amounts of colostrum. Although small in ineffective suck. This can happen with a fingers in this squeezing position as long as amount, colostrum is very important for sleepy full-term infant or a premature infant. milk is coming out. Then let go. Do the your baby’s health and should be saved same thing again. Continue to use this and fed to your baby. How do you express your milk? “milking” action in a rhythm. Your baby is usually more effective at Your situation may dictate which method of • Move your hand around the areola removing milk from your breasts than any expression you use. For example, if you need to reach all parts of each breast. Alternate method of expression. to be away from your baby full-time at work between breasts, or school, or if your baby is unable to continuing until enough milk has When would you need to express your breastfeed, it is recommended that you rent been expressed. breast milk? There are many an electric pump. Select one with a double • Remember that hand expression is like any circumstances when you might need to pumping kit so you can pump both breasts at other manual skill: it takes practice before express your breast milk. Any situation the same time for most effective milk you become good at it that requires you to be away from your baby removal and cut the time to complete a for more than a few hours or for a few pumping session in half. If you need to be feedings may require you to express some separated from your baby only occasionally, milk. a hand pump or hand expression may suit your needs. The amount you are able to In the first few days, as your milk supply express in one session will increases, you may become engorged (see also vary Figure 13. Expressing milk by hand. “Engorgement,” page 30) and expressing some breast milk will allow your baby to latch on more effectively. 36 37

USING A BREAST PUMP purchasing one, as many cover the cost of the • Get into a “pumping routine” by always • Wash your hands before touching your Several different types of breast pumps pump. Additionally, you can include the cost pumping in the same location(s) and breasts, any of the breast-pump parts, or are available: of breast pumps and supplies that assist keeping a picture of your baby, one of their your expressed milk lactation as medical expenses in your toys, or a blanket to look at while • Transfer your expressed milk into a clean Hospital-grade pumps produce the tax return. you pump glass or rigid plastic, food-safe container or closest imitation of both the pressure and Small handheld battery or electric • Try putting warm compresses on heavy-duty breast milk bag for storage rhythm of a baby’s sucking action. They are pumps are used to collect milk from one side your breasts for a few minutes • Label the container with the date and time the most appropriate choice when before expressing the milk is collected so you can be sure to breastfeeding is going to be delayed for a at a time. They vary in type and quality, from • Massaging, stroking, and gently shaking use the oldest milk first. You may also want considerable amount of time (as with a good to ineffective. Before purchasing one, your breast can help your milk to let down to mark the amount of milk you collect premature baby) and the most convenient if talk to someone who has used a handheld before and between episodes of expressing. • Put the container into a cooler or the you will be away from your baby for long pump successfully or ask a certified lactation There are several different techniques for refrigerator immediately (see specific storage periods on a regular basis (as when returning consultant for advice on which type to breast massage; and handling guidelines in the chart on page 40) to work or school). choose. This kind of pump is probably most here’s one: • Wash all the pump parts that come into appropriate for a limited amount of pumping, contact with your breast milk in hot, soapy A double-pump setup permits pumping as when you collect milk for an occasional – After washing your hands, place your water after each use; rinse well in hot water. both breasts at once. The advantages are separation from your baby. With practice, fingers on an area of your breast, starting Follow the manufacturer’s suggestions that it takes half the time to pump and can expressing your milk should take no longer back by the chest wall. Pressing firmly on about putting pump parts into the increase the level of prolactin, the hormone than about 30 minutes. Follow the your chest, move your fingers around in dishwasher. Milk storage containers should that tells your body to make milk. With a manufacturer’s instructions for the pump. small circles After a few seconds, move be washed the same way if they are to be double pump, it usually takes 10–15 minutes your fingers to the next area and reused to express your milk. If you do one side at a WHAT IF YOU HAVE PROBLEMS? massage. Do this all over your breast, • Freshly expressed milk contains time, it will take 10–15 minutes per side. If you have difficulty expressing your milk, moving little by little down toward the antibacterial factors that enable it to be don’t panic. This does not necessarily mean nipple. Repeat for the other breast kept at room temperature for up to 4 hours. These pumps are expensive to purchase, your milk supply is low. Some of the following – Next, do a light stroking all around the But to be on the safe side, place your milk in but they are available for rent on a weekly, tips may help you. breast from the base toward the nipple. a cooler or refrigerator as soon as possible monthly, or longer basis. They usually can Repeat for the other breast be rented from hospitals or medical supply • Relax. For about 5 minutes before – Then lean over and, with your back companies. If your baby is sick or premature, beginning to express, sit or lie in a parallel to the floor, shake your breasts check with your lactation consultant or a comfortable, quiet place and close your gently back and forth for a few seconds nurse from your hospital. Be sure to follow the eyes. Take several slow, deep breaths for the manufacturer’s instructions for use and first few minutes. When you feel yourself STORING AND HANDLING YOUR cleaning. relaxing, picture in your mind either your BREAST MILK baby breastfeeding well at your breast or Following are the basic procedures for If you and your baby don’t require a hospital your milk flowing freely from your breasts storing and handling your milk. If your baby grade pump you may still wish to have a as you express is premature or in a special-care nursery, double electric breast pump for when you check with your health care professional, as return back to work or school. Check with the recommendations may be different. your insurance company first before 38 39

• I f you intend to freeze your breast milk, do so within 24 hours after it is expressed. Before SPECIAL freezing, chill the milk in the refrigerator. Remember to leave 1” of space in the top of the breastfeeding situations container to allow for the expansion that occurs during freezing. • F reeze your milk in small (2- to 4-ounce) portions that will thaw fairly quickly ALTERNATE FEEDING METHODS If you are unable to feed your baby at the STORING breast, or if they need a supplement for any reason in the very early days, there are other your breast milk ways of feeding apart from using a bottle. 1 Although bottle feeding is the most common GUIDELINES FOR HEALTHY, FULL-TERM INFANTS choice for supplementation, it may interfere PLACE TEMPERATURE TIME LIMIT with breastfeeding, especially in babies 0 hours optimal, up to 4 hours if younger than 4 weeks of age. Room temperature 60–85°F or 16–29°C needed, 6-8 hours acceptable under very clean conditions Even though many babies do fine with a Small hard-sided cooler supplemental bottle, many parents do not with blue ice pack 59°F or 15°C 24 hours realize that there are alternatives. These options include feeding from a cup, a spoon, Refrigerator 39.2 F or ~4°C 4 days optimal, 5 – 8 days under an oral dropper, or a syringe; a device called a very clean conditions “nursing supplementer” can also be used. If Freezer

COMMON CONCERNS in later weeks ABOUT THE BABY This is known as shaken baby syndrome. • Movement often helps babies calm down. If you feel there is something wrong with Crying/Colic. Many new parents have Swaying back and forth or gently your baby, it is a good idea to have them a mental image of their baby calm and happy Coping with your newborn’s crying may be “bouncing” up and down may work. Some examined by their health care professional. in a crib while they go about their daily the most difficult part of your role as a new babies respond to a rhythmic patting or But there are many things that can cause a tasks. It can be surprising and disappointing parent. Here are some strategies to help you rubbing of their backs. Just walking around baby to cry; several were discussed in the if your baby does not meet this expectation, manage it: with baby in your arms or in an infant previous sections. We still do not fully but instead seems to cry a great deal of the carrier (sling) may be enough to put them understand what causes colic, and there are time they are awake. It is normal for your • Breastfeed. Even though your baby may not to sleep. Many babies are comforted by many different theories (and perhaps many baby’s crying to make you uncomfortable, be hungry, the sucking and the closeness to being rocked in a rocking chair; or you can different causes) for this kind of behavior. but crying is a way to make sure you attend you may be all baby needs to calm down try putting them in a stroller and taking a to baby’s needs. and go to sleep. One of the wonderful things walk. Even if your baby doesn’t settle down, Finally, some babies are just fussier than about breastfeeding is that it is more than the fresh air may help to brighten your others, and cry more frequently and for Most babies have fussy periods during the just food—it is a way of comforting your outlook longer periods. If this describes your baby, first several weeks of life, usually more baby that only you can provide • Babies tend to cry less when they are with sometimes your attempts to soothe them frequently than their parents had expected. • Breastfeed your baby before they are fully someone. Spend time snuggling your baby may be ineffective. Crying in the late afternoon and early awake and crying to be fed (when they are while you are both awake evening is very common. Some babies seem in the quiet alert state). Babies usually give • Older babies may be soothed by a warm to have their fussy period later in subtle “feeding cues” for a time before they bath the evening. get frantic and cry for a feeding. These cues include rooting, trying to put their hand in • Look around at your baby’s environment When their baby cries, many parents their mouth, and licking and smacking when they are crying. Are there lots of mistakenly blame their own lack of their lips stimulating things? Some babies are experience or their anxiety for the amount • Try to burp your baby more frequently. sensitive to overstimulation of fussiness. Some breastfeeding mothers There could be air in their stomach that is • Join a new parents group so that you can wonder if the crying happens because they making them uncomfortable meet and talk to others who are going don’t have enough milk or if something is • Try wrapping your baby snugly in a blanket through the same things. They may offer wrong with their milk. To make sure that (swaddling) and holding them very close to some good suggestions, and it always helps your baby is getting enough to eat and is not your body. Make sure they are warm to talk to someone who understands! crying because of hunger, you may want to enough but not too hot; some babies are Many parents have heard stories about colic have their intake and weight gain checked by very sensitive to temperature and, when their baby seems overly fussy, baby’s health care professional. • Try taking off everything but baby’s diaper worry that they have it. Parents whose No matter how frustrated you may become, and holding them on your chest against infants have colic often describe them as never shake your baby. Shaking a baby can your skin. Put a blanket over both of you to extremely difficult to console or cause blindness, serious brain damage, stay warm. Most babies find skin-to-skin demanding and intense. During periods of and even death. When a baby is shaken, contact very soothing intense crying, it seems that nothing works their unsupported head moves back and • Make sure none of baby’s clothing is to calm the baby, and something must be forth, causing serious damage inside too tight for comfort. Try changing wrong. the skull. baby’s diaper 42

Growth spurts. Sometimes your baby may These suggestions may help to get your baby BREAST REFUSAL want to be breastfed more often. These times to go to the breast: are referred to as “frequency days” and mean • Breastfeed while baby is sleepy. Babies who causes and solutions that they are probably going through a have fed well before this strike will often CAUSE SOLUTION growth spurt. Babies have periods when they take the breast before they are fully awake seem to have a sudden increase in their Reduced milk supply Call health care professional or lactation consultant for growth. Your baby will want to feed • Try to breastfeed in different positions than (baby frustrated by lack of milk) evaluation if baby has a weak or ineffective suck. Pump to frequently, which will build up your milk usual increase your milk supply. Breastfeed more frequently for supply to meet their new growth needs. It is • Try to get your baby to latch on while you longer periods. Switch back and forth between breasts important to let your baby breastfeed as are walking or rocking. The motion may frequently; this may help increase milk supply. often as they wish for the first few days that make them more likely to breastfeed this growth spurt lasts. Once your milk Yeast infection See section on “Yeast infection” (page 35). Both mother and supply has increased, your baby should settle (baby has sore mouth) baby will need treatment. back down into a pattern, feeding for about Pain Change baby’s nursing position so that no pressure is placed on the same length of time as before but will (such as from an injury the sore spot. take more milk at each feeding to satisfy Try to breastfeed in different or infection) their growth needs. Typical times for growth positions than usual spurts are at 2–3 weeks of age, 6 weeks, and Congestion Keep baby in an upright position. Breastfeed in a room where a 3 months, although they can occur at varying (baby can’t breathe through nose) vaporizer is running. Ask baby’s health care professional about times. using salt water drops and a nasal aspirator before feedings to clear baby’s nose and make breathing easier. Breastfeeding “strike”/breast refusal. • Use skin-to-skin contact as described in A breastfeeding strike occurs anytime your “Crying/colic,” page 43 Ear infection Check with the baby’s health care professional for appropriate baby refuses to breastfeed at all. Most strikes (sucking may increase pressure treatment. Keep baby in an upright position right before and can be overcome and breastfeeding can • Hand express or pump before feeding to get in baby’s ear) during feedings. Offer short, frequent feedings until pain in resume as usual. Sometimes this takes only your milk flow started ears is reduced. hours, but it may take several days and a lot Reactions to perfume or makeup Stop using the products to see if baby will resume of patience. Finding out the cause of the breastfeeding. strike can be crucial to solving the problem. The table on the next page lists some of the Overstimulation, stress, Make sure feeding times are not too rigid or frequently causes. or emotional upset interrupted. Try staying home and feeding in a quieter (any stressful event such as a environment for a few days. Stay close to baby after a move or prolonged separation prolonged separation. Talk quietly to your baby while from you may cause stress) breastfeeding. Eliminate as much stress as possible from your life. If your baby continues to refuse your breast and you can’t figure out why, you may express your milk and feed it to them in another way suggested by a certified lactation consultant. 44 45

WHILE YOU breastfeed ABOUT YOURSELF function, but it can make your milk Many women experience anxiety, mood Plugged ducts are more common during the Your activities. There are no health or taste sour. swings, irritability, and other emotional first 3 months of breastfeeding and may medical reasons why breastfeeding mothers Although your baby may not like the taste of changes, some of which last well past the occur for a number of reasons. One of the cannot participate in sports and exercise. your milk, the lactic acid won’t hurt him. first few weeks. Get enough rest, take breaks most common is when you skip a feeding or After the initial postpartum period is over Within about an hour after you have finished from baby care, exercise (even if you just two, such as when your baby starts to sleep (4–6 weeks) and your body has had a chance exercising, the taste should be gone. take regular short walks), and spend time through the night. Bras that are too tight or to recover from the birth, you should be able with other adults—all these help prevent have an underwire that presses on a milk to resume athletic activities you had been Returning to normal. Breastfeeding severe depression. Joining a new parents duct—or anything that puts too much doing before pregnancy. The only exception parents are often keen to understand when group, where you can take the baby and talk pressure on a duct—can cause plugging. The is that it is best to avoid contact sports, since their bodies will return to pre-pregnancy to other parents, may help. If you continue to plug by itself doesn’t require any treatment they could result in injuries to the breast(s). weight. Breastfeeding stimulates uterine be unable to focus on simple tasks or have with medication, but, if left unattended, it The increased physical activity may trigger contractions that assist the uterus in difficulty taking care of yourself, seek help may turn into a breast infection leaking of breast milk. If you breastfeed right becoming smaller. Though the process of from a counselor. (called mastitis). before participating in the sport, leaking is breastfeeding uses a large amount of energy Your normal menstrual cycle probably will The key to relieving a plugged duct and less likely to be a problem. It is a good idea to (calories), you will find that you get hungry not resume while you are breastfeeding. In preventing mastitis is to keep the milk wear a sports bra, since your breasts are and thirsty while breastfeeding, and you fact, most women do not have menstrual flowing freely from the affected breast. larger than before pregnancy and the need to attend to these signals. periods until breastfeeding is less frequent support will be welcome. Once you are beyond the first few (such as when the baby starts to eat solid Strategies to accomplish this include: Women have sometimes complained that postpartum weeks, the rapid and radical food, sleeps through the night, or receives • Take your bra off when you breastfeed their babies refused to breastfeed (or else fed changes that your body has undergone since regular feeding supplements). Be aware that • Apply warm heat (compresses) to very unenthusiastically) just after the delivery will slow down. You may still have neither breastfeeding nor lack of menstrual the area of the plug for 15 minutes mother exercised. If this happens to you, it puffy hands, legs, or feet for a few months. periods will necessarily prevent pregnancy. before feeding may be because when you exercise Some experience “night sweats” for a few Talk to your health care professional about vigorously, lactic acid appears in your breast weeks. When these occur, you may wake up methods of birth control. • Breastfeed frequently and, for milk. Lactic acid is a product of normal body during the night to find yourself drenched Plugged ducts/mastitis. It is normal for 24–48 hours, begin all feedings on with perspiration and needing a complete your breasts to feel generally lumpy, because the side where the plug is. If your baby change of clothes. These sweats are not due usually breastfeeds only on one side at a to breastfeeding, but to hormonal “ups and the milk ducts are filling and emptying during feeding, have her feed on the side with the downs.” the course of the day. Any lump that remains plug for as long as possible and express unchanged for 3 days needs to be evaluated by milk from the breast without Another postpartum event that is often your health care professional. the plug unexpected and may occur 6–12 weeks after If you feel a painful lump in your breast, you giving birth is a certain amount of hair loss. probably have a small blockage in a milk Although seldom severe, it can continue for duct. The skin over this area may be red and If you continue to be unable to several months. Both breastfeeding and slightly warm to the touch. When you have a focus on simple tasks or have bottle-feeding parents experience it. It, too, plugged duct, your milk cannot flow out of difficulty taking care of yourself, is caused by the influence of hormones, the area behind the blockage and it backs up. seek help from a counselor. which take hair follicles from a growing This causes that area of the breast to stay phase (present all during pregnancy) to a full, even after the baby has finished feeding. 46 resting phase. 47

• M assage the area above the blockage • Follow all the steps listed for getting rid of could cause an infection. Also, replace wet TRAVELING WITH YOUR while breastfeeding to help dislodge plugged ducts breast pads with dry ones as soon as BREASTFED BABY the plug • DO NOT stop breastfeeding. Stopping the possible. When you travel with your breastfed baby, it • P osition your baby so that their chin flow of milk will slow your recovery and may not be necessary to take along bottles or points toward the side with the plug for make the breast pain quite a When you feel your milk letting down in a any other feeding equipment. If you are maximum suction from that area. For bit worse non-feeding situation, apply direct pressure flying, it is a good idea to breastfeed during example, if the plug is on the outside of • If you are expressing milk to feed over your nipples to stop the flow. You can both takeoff and landing. Sucking and the breast, putting her in the football a preterm or sick infant in a special-care do this discreetly by crossing your arms and swallowing will lessen any discomfort in the hold would be ideal nursery and develop mastitis, inform your putting direct pressure against the nipples baby’s ears from pressure changes. When • Get mor e rest for at least a few baby’s health care with the heels of your hands. (If you have traveling as passengers in cars, never take days to increase your resistance professional immediately plugged ducts or mastitis, however, this may your baby out of the car seat to breastfeed to infection not be a good idea.) Many find that milk while the car is in motion. Leaking. Many parents find that, after the drips from one breast while their baby is • W atch for signs you have developed first few weeks of breastfeeding, their breastfeeding from the other one. You can let BREASTFEEDING IN PUBLIC mastitis: a fever over 101°F with chills breasts leak milk at certain times. Some the milk drip into a cloth diaper or towel to You can breastfeed while you are away from and body aches. Call your health women consider this only a minor avoid getting wet. You may leak milk at home and hardly be noticed. To make care professional if you have these annoyance and take it in stride; others find it night, especially when your baby starts to go nursing as easy and as discreet as possible: symptoms, as you will probably need to a major disturbance. for longer intervals between nighttime take an antibiotic feedings. If it is a problem, wear extra • Choose clothes that will work well for If you do get a breast infection, it is not The most common time to leak milk is nursing pads inside your bra and sleep on a breastfeeding, such as loose tops that can your milk that is infected, but the tissue when it has been a while since you last bath towel to keep your sheets dry. If you are be raised. Once the baby is in position and surrounding the ducts. You may suddenly breastfed. The sight of a baby, the sound of away from your baby for longer stretches, breastfeeding, the top will rest around your feel as if you are coming down with the flu crying, or even the thought of your child may such as at work, wear clothing that will baby’s head and upper body so that your and, along with your flu-like symptoms, you trigger a let-down, or milk ejection reflex. If camouflage the wetness, such as print breast is not seen. If you wear a top that will have a sore and probably reddened area leaking is due to your breasts becoming blouses—preferably not silk!—and keep a buttons up the front, unbutton it from the on the breast (usually on only one). overly full, breastfeeding or expressing milk jacket or sweater on hand as a coverup. bottom just far enough so you can put the more frequently may decrease the leaking. It Taking an extra bra and top to work can baby up to your breast If you have gotten particularly run-down is most common during the first few months • Drape a baby blanket, cardigan sweater, or from stress and fatigue, have had a cracked of breastfeeding and often stops or lessens help you deal with occasional problems jacket over your shoulder and your baby, nipple or a plugged duct, or have skipped by the time your baby is about 3 months old. of leaking. for even more screening several breastfeedings, you are more likely to If you try all of these suggestions and milk get mastitis. Breast pads or nursing pads worn inside • It is possible to buy clothing that is made your bra between feedings will keep your still gets on your sheets and clothing, rest specifically for this purpose Appropriate treatment measures are clothing dry. You can buy disposable nursing assured that it should wash out easily and • Wear bras that allow you easy access to as follows: pads or cloth ones that can be washed and should not stain. And the leaking may end your breast with one hand. Then you can reused. Some mothers even use cut-up cloth within 3 months. simply slip your hand and your baby under • Call your health care professional diapers or handkerchiefs folded into your shirt at feeding time immediately. Studies have shown quarters. No matter which kind of pad you that delay in treatment can lead to further use, be sure it does not have a plastic lining, complications which may hold in too much moisture and 48 49

SUMMARY A Helpful Guide to breastfeeding multiple babies Breastfeeding gives your baby a loving foundation for a healthy life. For every day that you breastfeed, you will have the satisfaction of knowing that you are enriching both your baby’s life and your own. The birth of twins, triplets, quadruplets, PUBLICATIONS FOR PARENTS or even more babies is exciting. But you If you would like additional information on the topics in this booklet, these books are good sources. may be wondering how you will care for Huggins K: The Nursing Mother’s Companion, ed 7. Boston, MA: Harvard Common more than one baby, especially if you want Press, 2015. La Leche League International Staff: The Womanly Art of Breastfeeding, ed 8. Schaumburg, to breastfeed. Perhaps you have heard that IL: La Leche League International, 2010. Mohrbacher N: Breastfeeding Made Simple: Seven Natural Laws for Nursing Mothers. breastfeeding multiple babies is difficult or Oakland, CA: New Harbinger Publications, 2010. impossible. Although people believe this, Neifert M: Dr. Mom’s Guide to Breastfeeding. New York, NY: Penguin Putman, Inc., 1998. it is not true in most instances. Spangler A: Breastfeeding: A Parent’s Guide, ed 9. Atlanta, GA: Self-Published, 2010. 50 51

BREASTFEEDING multiple babies It is true that breastfeeding 2 or more You also may be wondering how much time babies—especially if they are premature or breastfeeding will take and whether bottle come home from the hospital at different feedings would be more convenient with times—is not like breastfeeding 1 full-term such a hectic caregiving schedule. Again, the infant. You need information that is specific experiences of others are reassuring. to multiples so you can make the right Many parents of twins report that feeding decisions and get off to the best breastfeeding takes less time than possible start. preparing bottles and formula, especially This section summarizes the latest once they have mastered the technique of research and provides practical feeding both babies at once. Parents with suggestions for breastfeeding more than 1 more than 2 babies often—but not always— baby. You can use it in conjunction with combine some feedings at the breast with other resources that provide general bottle feedings of expressed milk or formula. information for breastfeeding 1 infant, like Many of these mothers say they had enough the first part of this booklet. You should milk for all their babies, but they needed discuss ideas with your family and health some help giving the feedings. care professionals so you can choose a If you are still undecided about breastfeeding plan that will work for you and breastfeeding, consider giving it a try. If you your babies. decide later that you don’t want to continue If you are still undecided breastfeeding, you can discuss how to DECIDING TO BREASTFEED The results of some recent studies may about breastfeeding, proceed with your baby’s healthcare Like most parents, you would like for your reassure you. For example, there are consider giving it a try professional. Feedings of your milk, even for babies to receive your milk because you are research reports about mothers who a short time, will provide your babies with aware of the special health benefits of exclusively breastfed twins and triplets important health benefits. breastfeeding. However, you may wonder through the first months of life. Although whether you can produce enough milk—or these women fed very frequently throughout whether it will be nutrient-rich enough—to the day, they were able to produce plenty of In fact, it is important to arrange for help support the growth of 2 or more babies. milk for their 2 or 3 infants. One report with all your other chores, so you can spend These common concerns about described the experience of a mother who the time that will be needed to breastfeed or breastfeeding multiples are often shared by had enough milk for quadruplets! So, with pump to establish your milk supply. You will friends, family, and even some health the right information and assistance, it is be very busy after your babies are born, but it care professionals. usually possible to breastfeed more is important to focus on getting your than 1 baby. breastfeeding off to a good start in the first few weeks. 52 53

PLANNING ahead MAKING ENOUGH MILK You can avoid some of the problems that lead SECURING SUPPORT FOR YOUR It is important to start breastfeeding or to a low milk supply if you know what to DECISION TO BREASTFEED expressing your milk right after giving expect and make some plans. • Inform your partner, support person, or birth. This is when your body will be helper and your health care professionals primed to make milk; so starting then One possible problem is that some twins, as early as possible in your pregnancy that will help establish a good milk supply. and most triplets and quadruplets, are born you plan to breastfeed. If they would like to The key to getting off to a good start in prematurely. They may not suckle strongly know more about breastfeeding multiples, breastfeeding multiples is establishing an enough or regularly enough in the early days you can share the list of support groups, abundant supply of milk. You will be able after birth to stimulate mother’s breasts to websites, and publications in the Appendix to do this best if you understand how your make an ample milk supply. Another is that section of this booklet body determines how much milk your mothers may not feel well for 24 to 48 hours • Ask your health care professional to babies need. after delivery, when breast stimulation is so refer you to a breastfeeding specialist, important. This is especially true if the such as the lactation consultant who is Studies have shown that milk volume is mother had pregnancy-related problems affiliated with the hospital where you determined mainly by the amount of milk resulting in long periods of bed rest, will give birth. Plan to meet with this that is removed from the breasts, rather medications to treat blood pressure or person during your pregnancy to than by the ability to make milk. In these premature labor, or a cesarean delivery. As a discuss your breastfeeding plans and studies, mothers with an established milk result, milk production and removal might goals. Some hospitals offer breastfeeding supply were asked to use a breast pump in be delayed. Here are some steps you can take classes. You may also find useful addition to feeding their babies. Researchers to prepare yourself and your family before information by attending meetings of your found that the daily milk volume increased your babies are born. local La Leche League with increased removal through breast- The key to getting off to • Talking with someone who has breastfed pump use, and decreased again when a good start breastfeeding the same number of infants that you are pumping was stopped. For parents of expecting can be very helpful. Often, your multiples, this means that the body will multiples is establishing an breastfeeding specialist or La Leche League know to make enough milk for more than 1 abundant supply of milk group can help by putting you in touch with baby provided the breasts are emptied a parent who has breastfed twins or frequently and completely throughout the triplets. The organizations listed on pages day. 67–68 are other excellent sources of information about caring for multiples and can refer you to parents who have breastfed multiples 54 55

IF ALL BABIES REMAIN WITH YOU in the hospital GETTING STARTED IN THE HOSPITAL With the excellent prenatal care that is Fortunately, these premature feeding Specific guidelines for starting to breastfeed available today, many twins and triplets are behaviors are temporary and will correct or for expressing your milk will depend on born after 34 weeks of gestation and weigh themselves as your babies approach their the condition of your newborn babies and at least 4½ to 5 pounds at birth. These larger expected birth dates. Until that time, you your breastfeeding goals. Whether you have premature babies are often healthy and do may need to provide some feedings of your twins, triplets, quadruplets, or even more not need to be admitted to the NICU. If this milk by bottle or another method, or use a babies, your situation will fall into one of the is true of your babies, they will remain with small, ultra-thin silicone nipple shield while SECURING A BREAST PUMP FOR following categories: you for feedings. Remember, though, that if breastfeeding. You will become aware of IN-HOSPITAL USE your babies are born 2 weeks or more before more mature feeding behaviors as your When you discuss your breastfeeding plans • All of your babies are healthy or just their expected birth date, they may not babies begin to awaken regularly, feed with your health care professionals and the slightly premature. They remain with you breastfeed as consistently, frequently, or eagerly, and take enough milk before falling lactation specialist, ask that a hospital-grade after birth, and are not admitted to the effectively as full-term babies. For this asleep. In the meantime, you will need to use electric breast pump with a double neonatal intensive care unit (NICU) reason, they may not provide the stimulation an electric breast pump in addition to collecting kit be put in your hospital room • All of your babies are premature. that your breasts need to produce enough breastfeeding to maintain your milk supply. after you give birth. You will need the They are admitted to the NICU milk for more than 1 baby. You will need BALANCING MILK EXPRESSION breast pump even if your babies are able to • One or more of your babies is in the NICU. special breastfeeding strategies for these AND BREASTFEEDING feed at the breast. If the hospital cannot You have the other(s) with you in your premature babies. To provide enough breast stimulation during provide a pump for your own exclusive use, hospital room and/or at home Although each situation will be a little the first week after birth, ideally each baby then you may want to arrange to rent an different, here are some guidelines to get you should feed actively at least 8 times a day for electric pump and take it to the hospital with started in the hospital if your premature a minimum of 10 minutes at each feeding. If you. babies are healthy and remain with you. 1 or all of your babies cannot do so, use the It is very important for a pump to be electric breast pump to “make up” for those available so that your breasts can be PREMATURE FEEDING BEHAVIORS feedings. Your priority should be to stimulated and emptied every 2–3 hours AND MILK VOLUME establish an adequate milk supply with during the first few days after your babies Healthy premature infants who do not the pump. Then you will have plenty of are born. It is a good idea to learn the require NICU admission typically do not milk by the time your babies are able to principles of how the breast pump works wake at regular times to feed, may suck feed well at the breast. Another family before your babies are born. However, weakly for only a few minutes, and may fall member can give any milk that you express you should not try to use the pump on asleep at the breast before they take enough to your babies, or it can be frozen and used yourself before you deliver, because this milk. If this is the case with any of your later. could cause contractions and bring on babies, you cannot rely on their sucking early labor. Ask a nurse or the lactation alone—especially in the early days of birth— specialist to show you how to assemble and to build an abundant milk supply. That is position the pump correctly. Make sure that because each baby is not emptying your another family member or helper knows breasts frequently and completely, and your how to operate the pump as well. You may body will not get the message that milk is need help holding the pump at one breast needed for more than one infant. while you feed a baby at the other breast. 56 57

IF YOUR BABIES ARE admitted to the NICU There are 2 main ways to use the pump to If your babies are admitted to the NICU, possible, keep a photograph of your babies in build your milk supply while still feeding your chances are they will not be ready to feed at front of you when you pump. This will make babies at your breasts. One way is to express the breast in the first 24 to 48 hours. it easier to express your milk. milk for 10 minutes after each breastfeeding, However, you will need to start expressing making sure that you pump at least 8 times your milk so that your breasts receive the each day. Or you can feed 1 baby at the breast necessary stimulation and you produce the while someone holds the pump at the opposite colostrum your babies need. If you’re not breast. The suction pattern of the pump at 1 feeling well after delivery, someone may breast will help keep milk flowing to your baby assist you with pumping. from the other breast. If you pump and Start by sitting in a large chair or on your breastfeed at the same time, be sure to bed, with pillows supporting each arm. EXPRESSING MILK alternate sides for pumping and feeding so Begin with the baby who feeds more eagerly. If you plan to exclusively breastfeed your that each breast can be completely emptied on Cradle that baby under your arm in a babies, you should use the breast pump at a regular basis. “football hold”* on the side you will use to least 8 times a day. During the first several breastfeed. Cup that baby’s head and days, you may pump only a few drops of FEEDING 2 BABIES AT A TIME shoulders with your hand. Use your other milk. After 14 to 21 days of this frequent milk In the beginning, it is usually easiest to feed hand to support your breast. expression, you should be producing about one baby at a time, using a position that 25 to 30 ounces each day, which should be supports the baby’s head and upper body. Once the baby is feeding well, have someone plenty of milk for 2 or 3 babies each When one of your babies attaches to your help you position your other baby at the weighing about 3 pounds. If you plan to FEEDING YOUR EXPRESSED MILK breast and sucks eagerly for several opposite breast. Move the hand that is breastfeed exclusively, your goal should be minutes without slipping off the breast, supporting the breast for your first baby and about 15 ounces of milk each day for each TO MORE THAN 1 BABY you can start feeding 2 babies at once. For use it to position the other baby in the baby by the time they are discharged from Colostrum the first few times you try this, have someone football hold at the opposite breast. Your the NICU. Even though all of your babies are in the there to help you. helper can assist with supporting your NICU, they may have different health breasts and can reattach an infant who slips Several things will make it easier for you to conditions that influence when and how off the breast. Another approach is to use express milk for your hospitalized babies. If they will receive your expressed milk. both hands to feed 1 baby while your helper the NICU has not placed your babies next to Colostrum, the milk that you produce during positions and supports the other baby. each other, ask that their incubators or the first 3 or 4 days of milk expression, is bassinets be moved, so that you can be near rich in substances that protect babies from Once both babies stay attached well to the all of them at the same time. Second, ask to infection and other prematurity-related breasts for feeding, any of several positions use your electric pump at your babies’ problems. It is especially easy for babies can be used to breastfeed 2 babies. After you bedsides. Expressing milk where you can to digest. are home and all your babies are feeding see and touch your babies may help your well, breastfeeding 2 of them at breasts empty more completely and boost For these reasons, you will want to make sure a time will be quick and efficient. your milk supply. Doing this also means you that all of your small, premature babies do not need to spend visiting time away from receive colostrum as their first feedings. your babies in a pumping room. If this is not 58 *See page 16 for a detailed description of the football hold. 59

IF YOUR BABIES ARE separated In special cases, parents purposely separate It is very difficult for parents of multiples baby finishes. This milk can be taken their foremilk and hindmilk during milk to have their babies separated. This can to the NICU for the hospitalized baby. expression because they want to feed only occur when some infants are able to go home the hindmilk to their babies. Because and others must remain in the NICU. A BREASTFEEDING THE hindmilk contains concentrated fat and mother may feel guilty about having little HOSPITALIZED BABY calories, it can help premature babies gain time to breastfeed the baby who remains Most parents find that when babies are weight more quickly (if the doctor prescribes in the hospital because they are so busy separated between home and hospital, they hindmilk for your babies). A nurse or caring for and breastfeeding the babies who can breastfeed the hospitalized baby only lactation specialist will help you with this are at home. In addition, traveling to and once a day. Although you may worry that Label your colostrum so that the NICU technique. Freeze the foremilk and keep it at from the hospital makes the schedule even frequent bottle feedings will make it difficult staff will realize that it is different from home. You can feed it to your babies after more hectic. Even though there is no for the hospitalized baby to breastfeed after your later milk. Then find out what they are discharged from the hospital. “right” way to breastfeed under these coming home, there are no facts to support tracking system your babies’ nurses will circumstances, many parents and caregivers this idea. If you have established an use to ensure that all babies receive manage as follows. abundant milk supply and if your at-home colostrum. This is especially important if 1 baby is used to breastfeeding, your baby does not get started with feedings as hospitalized baby should be able to feed early as the others. Some colostrum should from the breast with a little practice. be frozen and saved for the baby who begins feedings later. FOREMILK AND HINDMILK When expressing milk for more than 1 baby, In general, the baby at be aware that there are differences in fat and home should feed at only 1 calories between your foremilk and hindmilk. breast each feeding Foremilk, which flows during the first few minutes of milk expression, looks thinner and is lower in fat and calories than hindmilk, which flows later. Take extra care to BREASTFEEDING BABY AT HOME thoroughly mix all of the milk from each The baby who is at home with you should be breast before you separate it into the sterile breastfed as frequently as possible, so that storage containers for your babies. This will this baby will be a skilled feeder by the time ensure that each baby is fed a mixture of your other baby comes home. Then, when all foremilk and hindmilk and receives adequate babies are home, you’ll be able to spend extra fat and calories to grow well. time helping the baby who was just discharged become accustomed to the breast. In general, the baby at home should feed at only 1 breast each feeding. Then use the pump to empty both breasts when that 60 61

OTHER QUESTIONS ABOUT breastfeeding multiples complete feeding. However, 1 of your babies Triplets and quadruplets may awaken more consistently and feed If you feed triplets and quadruplets in more eagerly from the breast than the sequence, keep in mind the differences other(s). If you must wake the sleepy baby between foremilk and hindmilk that were every 3 hours for feedings, try to get the discussed earlier. Infants who feed first will more eager feeder on the same schedule. usually receive more milk, but it will be a That way you can feed both of them at the lower-fat, lower-calorie milk. Infants who same time. The baby who feeds eagerly may feed afterward usually receive less milk, but start and maintain the milk flow for the it will be much higher in calories. Typically, sibling who feeds less strongly and parents of triplets who exclusively effectively. breastfeed manage by feeding 2 babies at ALTERNATING BREASTS once, then feed the third infant at both breasts. For quadruplets, mothers feed 2 Once all of your babies are home with you, AMONG BABIES babies at a time. It is very important that COMBINING BREASTFEEDINGS AND you are likely to have several breastfeeding Twins triplets and quadruplets who breastfeed BOTTLE FEEDINGS questions: how frequently should I feed my The main reason for alternating breasts exclusively alternate between being first and It is usually convenient for parents of twins to babies? Should I alternate breasts? How do I between twins is to balance the milk volume second feeders, so that each baby receives a breastfeed exclusively once they are able to combine breastfeedings with bottle feedings that each breast produces. This is especially mixture of foremilk and hindmilk each day. feed both babies at a time. But mothers with of expressed milk or formula? How will I important when the 2 babies have different “more babies than breasts” often choose to know my babies are taking enough milk from sucking styles. One who feeds vigorously will combine some breastfeedings with bottle the breast? These questions are answered on stimulate more milk volume than will a feedings, especially in the beginning if they the next few pages. You may also want to sleepy, less effective feeder. If you alternate If you feed triplets and have premature babies who take a longer time discuss them with your babies’ health care breasts, the sleepier baby will benefit from quadruplets in sequence, to feed—and who may be unable to breastfeed professional or a breastfeeding specialist. the extra milk that the more vigorous baby keep in mind the simultaneously. In many instances, these creates, and both breasts will remain differences between women have enough milk for their babies but FREQUENCY OF FEEDINGS approximately the same. foremilk and hindmilk need extra help in giving the feedings. Although healthy full-term multiples should feed on demand (8 to 12 times a day), For twins, you can alternate breasts during a The decision to combine breastfeeding and premature multiples may not “demand” feeding, for each feeding, or from day to day. bottle feeding is based on many things, on a regular basis until they are close to Some parents report that each twin has a including personal breastfeeding goals and their expected birth date. Until that time, “favorite” breast and prefers it for all the amount of caregiving help that be certain that each baby feeds at least 8 feedings. Once both babies empty the breast is available. times a day and has no more than one effectively, you do not need to alternate Your babies may have individual preferences 5-hour-sleep stretch a day. breasts and babies. One mother’s small that help you decide how to feed them. One While it is possible to feed 2 infants at the premature twins preferred the same breast, mother said that 3 of her quadruplets same time, it is more difficult with so, for the first week or so at home, she fed adapted easily to a combination of breast and premature babies until they are able to both of them from her right breast and used bottle, but the fourth baby refused bottles “demand” and stay awake long enough for a the pump on her left breast. Soon the babies and would feed only at the breast. were feeding from both breasts. 62 63

With multiples, it is important to GETTING ENOUGH MILK AT THE BREAST remember that there is no right or wrong Here are some suggestions for easing any concerns you have about producing enough breast way to combine bottle feedings and milk for more than 1 baby. breastfeedings. For example, if a Keep a record breastfeeding mother of twins uses a bottle, it is usually before she has mastered feeding Parents report that keeping a daily record of milk intake, wet diapers, and bowel movements both babies at the same time. Until then, she for each baby is very important, at least for the first few weeks at home. In general, each baby can often express milk for bottle feedings so should feed at least 8 times a day, have a wet diaper with each feeding, and have at least 1 she can get an uninterrupted stretch of sleep, bowel movement each day. or so she can spend extra time helping 1 baby Since it is difficult to remember these things for each baby, simple checklists will help you breastfeed while someone else gives keep track of them. It is a good idea to take these records along when your babies visit their the other baby a bottle. health care professional for checkups. Several parent organizations for multiple babies have Parents of triplets often elect to breastfeed 2 sample forms that they are willing to share. (See the Appendix for more information and a infants at the same time while the third baby blank breastfeeding log you can copy and fill out.) bottle feeds. Feedings by breast and bottle are rotated so that each baby receives 2 out of 3 feedings at the breast. DATE NAME DATE NAME 5/ 7/ 0 Charlie Jones 5/ 7/ 0 Jess Smith Time Feeding Weight (g) Intake Urine Stool Time Feeding Weight (g) Intake Urine Stool In 1 family, triplets were breastfed description start/finish amount description start/finish amount exclusively during the day, and were given 6:00 AM BO (MM) 2098 / 2155 2 oz. X O 6:00 AM BR 2296 / 2353 2 oz. X X bottles at night because the parents said it 7:00 AM / 7:00 AM / 8:00 AM / 8:00 AM / 9:00 AM BR 2102 2154 2 oz. X X 9:00 AM BO (MM) 2300/ 2363 2¼ oz. X O was faster. The mother used the breast pump had much more milk than 2 babies could / while her partner fed a bottle of expressed 10:00 AM / 10:00 AM / consume, and she found that it was easier 11:00 AM / 11:00 AM / milk to 1 baby. Then they each gave a bottle 12:00 PM BR (hind) 2106 2169 2 oz. X O 12:00 PM BR (fore) 2305/ 2362 2 oz. X O not to keep a schedule. She breastfed as / of the freshly pumped milk to the second 1:00 PM / 1:00 PM / and third. often as she could, and expressed extra milk 2:00 PM / 2:00 PM / for bottle feedings when her babies all slept 3:00 PM BR (fore) 2110 / 2175 2 oz. X O 3:00 PM BR (hind) 2309/ 2366 2 oz. X X 4:00 PM / 4:00 PM / Another mother elected to breastfeed her for an extended stretch of time. Each day her 5:00 PM / 5:00 PM / triplets only as frequently as she would feed breastfeeding pattern was different, and she 6:00 PM BO (F) 2114 / 2171 2¼ oz. X X 6:00 PM BO (F) 2314 / 2371 2 oz. X O found this to be the simplest approach. 7:00 PM / 7:00 PM / a single infant. So she breastfed each infant 3 8:00 PM / 8:00 PM / to 4 times a day, for a total of 9 to 12 feedings 9:00 PM BR 2118 / 2175 2 oz. X O 9:00 PM BO (mm) 2327 / 2393 2½ oz. X O at her breasts. Bottle feedings of formula 10:00 PM / 10:00 PM / 11:00 PM / 11:00 PM / were given at other times. 12:00 AM BO (mm) 2126 / 2183 2 oz. X O 12:00 AM BR 2330 / 2394 2¼ oz. X O 1:00 AM / 1:00 AM / A mother of quadruplets planned during her 2:00 AM / 2:00 AM / 3:00 AM BR 2126 / 2183 2 oz. X O 3:00 AM BR 2338 / 2395 2 oz. X X pregnancy to feed 2 babies at the breast and 4:00 AM / 4:00 AM / 2 with a bottle of formula at each feeding. 5:00 AM / 5:00 AM / However, once all the babies were home, she 64 65

MEASURE INTAKE AND WEIGHT APPENDIX: If you are concerned about your milk supply for more information or your babies’ weight gain, talk with your babies’ health care professionals. They may Several organizations have special resources for parents with twins, triplets, and even more offer advice about monitoring the adequacy multiples. Most offer membership and newsletters, and many have products—such as of intake by monitoring the adequacy of expectant and/or new parent packages, pamphlets on speciality topics, and merchandise— output, or recommend frequent in-office designed especially for multiple infants. The following list of groups will help you get started, weight checks. Or, they may recommend you and their members can advise you whether local chapters of these or other organizations are rent a portable, electronic baby scale to available near your home. weigh each baby before and after feedings, as a way to approximate the amount of milk Multiples of America intake at each breastfeeding. Or you can Multiples of America (also known as the National Organization of Mothers of Twins Clubs, measure your babies’ weight gain on a daily Inc.) is a support group for parents of multiples. It provides a national network of resources basis. These scales can be rented from for local clubs that caregivers can use. Its basic purpose is to provide research, education, and breastfeeding specialists, hospitals, and support of multiple birth children and their families. medical supply companies. Multiples of America If it’s recommended that you weigh your Franklin, TN babies at home, share your babies’ weight www.multiplesofamerica.org gain patterns with their health care Email: [email protected] professional by phone, so that they can help Raising Multiples you monitor your babies’ growth between Raising Multiples was founded as MOST (Mothers of Supertwins) in 1987. It is a nonprofit office visits. provider of support, education and research on higher-order multiple births. They advocate for quality prenatal care, promote healthy deliveries, and supply information to all multiple SUMMARY birth families in order to support successful parenting through every phase of their This section is intended to help you in the children’s development. early days of breastfeeding your multiple Raising Multiples Other parents who have babies. Your health care professionals and a Purchase, NY breastfed more than 1 baby breastfeeding specialist can help you apply www.raisingmultiples.org are great resources of these principles to your special [email protected] support and information breastfeeding situation. However, other parents who have breastfed more than 1 baby are great resources of support and information. In particular, they can share their own experiences of combining breastfeeding with the other responsibilities involved in the care of multiple babies. With the support of family members, health care professionals, and other parents, you can breastfeed your multiple babies. 66 67

APPENDIX: references Multiple Births Canada Daly SE, Hartmann PE. Infant demand and milk supply: infant demand and milk production Founded in 1978 to provide support, education, research, and advocacy for parents of in lactating women. J Hum Lact. 1995;11:21-26. multiples and those involved in their care. This organization is the primary referral site Daly SE, Hartmann PE. Infant demand and milk supply: the short-term control of milk for multiples’ resources, events, and information in Canada. synthesis in lactating women. J Hum Lact. 1995;11:27-37. Multiple Births Canada 2 King Street West, Unit #155 Chapman DJ, Perez-Escamilla R. Lactogenesis stage II: hormonal regulation, determinants Hamilton, ON L8P 4S0 and public health consequences. Recent Res Dev Nutr. 2000;3:43-63. 1-866-228-8824 (toll free) multiplebirths.ca Gromada KK, Spangler AK. Breastfeeding twins and higher-order multiples. J Obstet Gynecol Neonatal Nurs. 1998;27:441-449. Lawrence RA, Lawrence MA. Breastfeeding: A Guide for the Medical Professional, 8th ed. Philadelphia: Elsevier; 2016. Mead LJ, Chuffo R, Lawlor-Klean P, Meier PP. Breastfeeding success with preterm quadruplets. J Obstet Gynecol Neonatal Nurs. 1992;21:221-227. Meier PP. Breastfeeding in the special care nursery: prematures and infants with medical problems. Pediatr Clin North Am. 2001;48:425-442. Meier PP, Brown LP, Hurst NM, et al. Nipple shields for preterm infants: effect on milk transfer and duration of breastfeeding. J Hum Lact. 2000;16:106-114. Meier PP, Engstrom JL, Crichton CL, et al. A new scale for mothers of preterm and high-risk infants. J Hum Lact. 1994;10:163-168. Saint L, Maggiore P, Hartmann PE. Yield and nutrient content of milk in eight women breast-feeding twins and one woman breast-feeding triplets. Br J Nutr. 1986;56:49-58. Schanler RJ. The use of human milk for premature infants. Pediatr Clin North Am. 2001;48:207-219. Schanler RJ. Breastfeeding 2001: the management of breastfeeding. Pediatr Clin North Am. 2001;48:273-551. Sollid DT, Evans BT, McClowry SG, et al. Breastfeeding multiples. J Perinat Neonatal Nurs. 1989;3:46-65. 68 69

APPENDIX: Breastfeeding log DATE NAME DATE NAME / / / / Feeding Weight (g) Intake Time Feeding Weight (g) Intake Urine Stool Time description start/finish amount Urine Stool description start/finish amount 6:00 AM / 6:00 AM / 7:00 AM / 7:00 AM / 8:00 AM / 8:00 AM / 9:00 AM / 9:00 AM / 10:00 AM / 10:00 AM / 11:00 AM / 11:00 AM / 12:00 PM / 12:00 PM / 1:00 PM / 1:00 PM / 2:00 PM / 2:00 PM / 3:00 PM / 3:00 PM / 4:00 PM / 4:00 PM / 5:00 PM / 5:00 PM / 6:00 PM / 6:00 PM / 7:00 PM / 7:00 PM / 8:00 PM / 8:00 PM / 9:00 PM / 9:00 PM / 10:00 PM / 10:00 PM / 11:00 PM / 11:00 PM / 12:00 AM / 12:00 AM / 1:00 AM / 1:00 AM / 2:00 AM / 2:00 AM / 3:00 AM / 3:00 AM / 4:00 AM / 4:00 AM / 5:00 AM / 5:00 AM / (Conversion: 1 ounce = 30 grams of weight gain = 30 mL of intake) BR: Fed at breast Amount: V olume of milk (if you are using a scale to measure Sample of a 24-hour log during the early weeks. You can use the form to give you and your babies’ care provider the amount Fore: Infant fed at the beginning of feeding, leaving hindmilk for intake). Coded in number of ounces, example: “2½.” of detail (such as amount of milk or time spent with each feeding) that is needed. For some babies, only “BR” or “BO” may another infant. (This infant consumes more volume, but less fat BO: Fed with a bottle be enough. For other babies, more specific information may be helpful. The following codes may give you some ideas: and fewer calories.) Coded as “F” for foremilk. Type: Type of milk in the bottle. Coded as: Mother’s milk (MM) or Hind: Infant fed at both breasts after sibling had finished drinking the Formula (F). foremilk. (This infant takes less volume, but the milk has more fat and calories.) Coded as “H” for hindmilk. 70 71

YOUR YOUR notes notes 72 73

YOUR YOUR notes notes 74 75

Abbott supports breastfeeding as the optimal form of nutrition. We advocate breastfeeding as the first choice for infants and agree with the American Academy of Pediatrics (AAP) and other leading medical and health organizations that breastfeeding is the best form of infant nutrition. Abbott has prepared this booklet for breastfeeding parents to provide information in support of their choice to breastfeed. Abbott provides this information to health care professionals to help counsel patients. 76 ©2022 Abbott 20219319/June 2022 LITHO IN USA